1. Which of the following delegations by the RN would require an immediate intervention by the
charge RN?
Answer: A UAP replaces the monitor electrodes on a patient after he has taken a shower.
2. You are the nursing supervisor on the 11 PM to 7 AM shift. When making rounds, the charge
nurse on the unit reports that one of the patients is dyspneic. What action would be expected
from a nurse in the expertise stage of clinical competence when assessing shortness of breath in
a patient?
Answer: Recognizes the patient may have pulmonary edema and orders (or asks the physician for an
order) an IVP diuretic
3. Walking rounds are currently being implemented to avoid errors or omissions in shift reports.
Which observations made during walking rounds would be seen as an advantage to the shift
report? (Select all that apply.)
Answer: IV infusion bag is nearly dry.; IV line is not infusing what is currently ordered. ; Foley bag is not
emptied on a patient on strict I&O.
4. After receiving the shift report, which of the following requires a priority action by the nurse?
Answer: Discontinue an IV line from an insertion site that appears red and at which the patient
complains of pain.
5. Patients are complaining that they are not receiving pain medications on the night shift. The
night nurse has charted that they were given. What is the most appropriate action by the charge
nurse?
Answer: Notify the nurse manager.
6. A staff nurse complains to the nurse manager about an employee of another department
constantly asking her out on a date even though she has told him she is not interested.
Which action by the nurse manager is most appropriate?
Answer: Review the personnel manual to decide on the next step.
7. You are the nurse manager who is preparing the annual reviews for the staff members. You are
aware that the nurse in the competent stage of clinical performance development would be
expected to do what when assigned a patient on beta-blockers scheduled for a stress test?
Answer: Calls the physician for an order to hold the beta-blocker prior to a stress test if there is no order
8. The nurse is admitting a patient who speaks very little English. What is the most appropriate
method to use to ensure the patient understands the instructions?
Answer: Obtain a hospital interpreter.
, 9. You are the charge nurse on the 3 PM to 11 PM shift. The nurses on this shift range from novice
to competent. What response would be expected in the beginner stage of clinical competence
development when the nurse is assigned a patient on beta-blockers and scheduled for a stress
test?
Answer: Knows to hold a beta-blocker on a patient scheduled for a stress test because this happened
earlier in the week on another patient
10. A nurse takes a telephone order from a physician. Which procedure is best for the nurse to use
to avoid errors?
Answer: Repeat the order, write the order verbatim, and read the order back to the physician
11. A surgeon approaches the charge nurse in an angry manner after his patient fell out of bed,
requiring further surgery. Which of the following approaches is most appropriate for the charge
nurse to use?
Answer: Can you step over here out of the hearing of the patients and family members
12. Point-of-care systems are currently being used in health care facilities. Which is an advantage of
the point-of-care systems to the patients? (Select all that apply.)
Answer: Documentation at the time of care; Documentation at the bedside; Immediate access to
decision support systems
13. Which delegation should a UAP consider to have the highest priority?
Answer: Helping an older adult patient to the bathroom
14. Which of the following is an essential part of the shift report?
Answer: Patient’s ECG rhythm
15. To avoid transcription errors, the current trend in hospitals is to use the Computerized Physician
Order Entry (CPOE). Further instructions should be given to the nurses when which statement is
made?
Answer: I don’t need to review the new orders for accuracy
16. When incorporating the five rights of delegation, the right circumstance is used in which of the
following situations?
Answer: The RN asks the UAP to draw blood on a newly admitted patient with pneumonia
17. The nurse and UAP are working together with four patients. Which patient should the nurse
assign the UAP?
Answer: A patient with diabetes who needs her blood glucose checked
, 18. All treatments and services for patients require two forms of patient identification prior to
providing those services. Which would require an intervention if used by the nurse to identify a
patient? (Select all that apply.)
Answer: Asking another nurse on the unit ; Asking the roommate
19. It is vital to communicate changes in patient condition to the physician. When using the SBAR
process, the nurse knows that what should be included when communicating patient condition?
(Select all that apply.)
Answer: Lab data; problem; diagnosis; assessment
20. A patient is inappropriate when speaking to a UAP. What is the most appropriate action by the
nurse?
Answer: Explain to the patient how what they say is being interpreted
21. Which action by a UAP requires an immediate intervention by the nurse?
Answer: Application of a skin barrier/protection ointment
22. The nurse is working on a medical unit with an LPN and UAP as the team members. Which tasks
should the RN delegate to the LPN?
Answer: Administration of all oral medications for the team
23. Which of the following delegations require an immediate intervention by the charge RN?
Answer: A UAP ambulates a patient 24 hours after a pneumonectomy
24. The computerized provider order entry (CPOE) is a component of the electronic health care
system being used in hospitals. This system allows prescriptions to be written electronically and
automatically sent to the pharmacy or other necessary facilities. The nurse understands that the
greatest benefit of the CPOE is
Answer: that fewer errors occur
25. A nurse assesses a patient reported to have normal vital signs throughout the night and finds the
patient in acute respiratory distress. What is the nurse’s next best action?
Answer: Ask another nurse to call the health care provider.
26. Which observation requires an intervention of a new graduate nurse by her preceptor?
Answer: Leaving patient room without charting vital signs
charge RN?
Answer: A UAP replaces the monitor electrodes on a patient after he has taken a shower.
2. You are the nursing supervisor on the 11 PM to 7 AM shift. When making rounds, the charge
nurse on the unit reports that one of the patients is dyspneic. What action would be expected
from a nurse in the expertise stage of clinical competence when assessing shortness of breath in
a patient?
Answer: Recognizes the patient may have pulmonary edema and orders (or asks the physician for an
order) an IVP diuretic
3. Walking rounds are currently being implemented to avoid errors or omissions in shift reports.
Which observations made during walking rounds would be seen as an advantage to the shift
report? (Select all that apply.)
Answer: IV infusion bag is nearly dry.; IV line is not infusing what is currently ordered. ; Foley bag is not
emptied on a patient on strict I&O.
4. After receiving the shift report, which of the following requires a priority action by the nurse?
Answer: Discontinue an IV line from an insertion site that appears red and at which the patient
complains of pain.
5. Patients are complaining that they are not receiving pain medications on the night shift. The
night nurse has charted that they were given. What is the most appropriate action by the charge
nurse?
Answer: Notify the nurse manager.
6. A staff nurse complains to the nurse manager about an employee of another department
constantly asking her out on a date even though she has told him she is not interested.
Which action by the nurse manager is most appropriate?
Answer: Review the personnel manual to decide on the next step.
7. You are the nurse manager who is preparing the annual reviews for the staff members. You are
aware that the nurse in the competent stage of clinical performance development would be
expected to do what when assigned a patient on beta-blockers scheduled for a stress test?
Answer: Calls the physician for an order to hold the beta-blocker prior to a stress test if there is no order
8. The nurse is admitting a patient who speaks very little English. What is the most appropriate
method to use to ensure the patient understands the instructions?
Answer: Obtain a hospital interpreter.
, 9. You are the charge nurse on the 3 PM to 11 PM shift. The nurses on this shift range from novice
to competent. What response would be expected in the beginner stage of clinical competence
development when the nurse is assigned a patient on beta-blockers and scheduled for a stress
test?
Answer: Knows to hold a beta-blocker on a patient scheduled for a stress test because this happened
earlier in the week on another patient
10. A nurse takes a telephone order from a physician. Which procedure is best for the nurse to use
to avoid errors?
Answer: Repeat the order, write the order verbatim, and read the order back to the physician
11. A surgeon approaches the charge nurse in an angry manner after his patient fell out of bed,
requiring further surgery. Which of the following approaches is most appropriate for the charge
nurse to use?
Answer: Can you step over here out of the hearing of the patients and family members
12. Point-of-care systems are currently being used in health care facilities. Which is an advantage of
the point-of-care systems to the patients? (Select all that apply.)
Answer: Documentation at the time of care; Documentation at the bedside; Immediate access to
decision support systems
13. Which delegation should a UAP consider to have the highest priority?
Answer: Helping an older adult patient to the bathroom
14. Which of the following is an essential part of the shift report?
Answer: Patient’s ECG rhythm
15. To avoid transcription errors, the current trend in hospitals is to use the Computerized Physician
Order Entry (CPOE). Further instructions should be given to the nurses when which statement is
made?
Answer: I don’t need to review the new orders for accuracy
16. When incorporating the five rights of delegation, the right circumstance is used in which of the
following situations?
Answer: The RN asks the UAP to draw blood on a newly admitted patient with pneumonia
17. The nurse and UAP are working together with four patients. Which patient should the nurse
assign the UAP?
Answer: A patient with diabetes who needs her blood glucose checked
, 18. All treatments and services for patients require two forms of patient identification prior to
providing those services. Which would require an intervention if used by the nurse to identify a
patient? (Select all that apply.)
Answer: Asking another nurse on the unit ; Asking the roommate
19. It is vital to communicate changes in patient condition to the physician. When using the SBAR
process, the nurse knows that what should be included when communicating patient condition?
(Select all that apply.)
Answer: Lab data; problem; diagnosis; assessment
20. A patient is inappropriate when speaking to a UAP. What is the most appropriate action by the
nurse?
Answer: Explain to the patient how what they say is being interpreted
21. Which action by a UAP requires an immediate intervention by the nurse?
Answer: Application of a skin barrier/protection ointment
22. The nurse is working on a medical unit with an LPN and UAP as the team members. Which tasks
should the RN delegate to the LPN?
Answer: Administration of all oral medications for the team
23. Which of the following delegations require an immediate intervention by the charge RN?
Answer: A UAP ambulates a patient 24 hours after a pneumonectomy
24. The computerized provider order entry (CPOE) is a component of the electronic health care
system being used in hospitals. This system allows prescriptions to be written electronically and
automatically sent to the pharmacy or other necessary facilities. The nurse understands that the
greatest benefit of the CPOE is
Answer: that fewer errors occur
25. A nurse assesses a patient reported to have normal vital signs throughout the night and finds the
patient in acute respiratory distress. What is the nurse’s next best action?
Answer: Ask another nurse to call the health care provider.
26. Which observation requires an intervention of a new graduate nurse by her preceptor?
Answer: Leaving patient room without charting vital signs
