RN Leadership a Rational questions and
correct answers 2024\2025 A+ Grade
There has been a community disaster and stable clients must be discharged from a facility to prepare for
the influx of new casualties. A nurse should identify that which of the following clients is safe to
discharge?
- correct answer a client who has multiple sclerosis and reports ataxia
This client is safe to discharge because multiple sclerosis is a chronic disorder and ataxia is an expected
finding.
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the
following clients is the priority?
- correct answer A client who has peripheral vascular disease and has an absent pulse in the right foot
When using the airway, breathing, circulation approach to client care, the nurse determines that the
priority finding is an absent pulse, which indicates no blood flow to the extremity.
A nurse finds that a new IV pump has infused 400 mL of solution over 2 hr when the rate was set at 100
mL/hr. After notifying the provider and verifying that the pump was properly programmed, which of the
following is the nurse's priority?
- correct answer Tag the pump for maintenance and acquire a new pump for the client
The greatest risk is the potential for injury to a client if a nurse uses the pump again before repair;
therefore, the priority for the nurse is to tag the pump for maintenance and acquire a new pump for the
client.
,A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated
to an assistive personnel (AP)? select all that apply
- correct answer ambulating a client who uses a walker, adding thickener to thin liquids on a client's
food tray
Flushing a client's saline lock is incorrect. This is not within the AP's scope of practice.
Ambulating a client who uses a walker is correct. This is within the AP's scope of practice.
Adding thickener to thin liquids on a client's food tray is correct. This is within the AP's scope of practice.
Teaching a client how to use an incentive spirometer is incorrect. This is not within the AP's scope of
practice.
Evaluating a client's gag reflex before mealtime is incorrect. This is not within the AP's scope of practice.
A nurse is caring for a client. Which of the following tasks should the nurse delegate to an assistive
personnel (AP)? select all that apply
- correct answer Place an absorbent pad on the client's bed, report the client's blood pressure to the
nurse, apply barrier cream to the client's buttocks, document the client's vital signs
A charge nurse on a maternal newborn unit is receiving change of shift charge nurse report for a group
of newborns. Which of the following 3 newborns should the charge nurse identify as requiring priority
care? Select 3 newborns the charge nurse should identify as priority.
- correct answer Newborn 5, Newborn 3, Newborn 1
When prioritizing hypotheses using the urgent vs. non-urgent approach to newborn care, the charge
nurse should identify newborn 1, newborn 3, and newborn 5 as requiring priority care based on acuity.
Newborn 1 has manifestations of respiratory distress including tachypnea, grunting, nasal flaring, and
retractions. The charge nurse should further determine if newborn 1 requires prompt interventions.
Newborn 3 presents with manifestations of hypoglycemia including blood glucose below the expected
range, hypothermia, and maternal history of gestational diabetes insulin dependent. Newborn 5 is 23
hours of age and has not had a successful feeding. The newborn additionally has not voided or passed
their first meconium stool. Newborns are expected to have at least one void during the first 24 hours of
life, and one meconium stool with in the first 24 to 48 hours of life. While newborns are sleepier during
the first 48 hours after birth, the newborn should be awoken for feedings at least every 3 hours. These
finding indicate that further intervention by the nurse is needed.
, A nurse manager is assessing incident reports for the unit. Which of the following client's medical
records indicate professional negligence? Select 2 clients that the nurse manager should recognize have
charts that indicate professional negligence.
- correct answer Client 4, Client 5
When recognizing cues, the nurse should identify client 4 and client 5 have medical records that indicate
instances of professional negligence. Professional negligence occurs when an individual with
professional training fails to practice at the level expected of their profession and harm is caused to a
client. For professional negligence to occur there must be a correlation between the nurse's actions and
the harm that came to the client. In client 4's medical record, the nurse failed to administer the client's
prescribed antiseizure medication within the indicated time frame and the client experienced a seizure.
In client scenario 5's medical record, the nurse administered the client's medications outside the
parameters indicated on the prescription and the client experienced syncope and sustained an injury.
The nurse should identify these two client scenarios as instances of professional negligence.
A charge nurse is assisting with the care of a client. Which of the following findings should the charge
nurse identify that the client is experiencing an adverse reaction and requires notification of provider
and updating the client's plan of care? Select 6 findings that indicate that client is having an adverse
reaction.
- correct answer blood pressure, temperature, heart rate, respiratory rate, pain level, report by the
client
When evaluating outcomes, the nurse should identify hypotension, an increase in temperature, heart
rate, and respiratory rate along with reports of abdominal and flank pain as a 6 on a pain scale from 0 to
10 and client report of short of breath and chills can indicate the client is experiencing an acute
hemolytic reaction to the blood transfusion. The nurse should stop the transfusion and notify the client's
provider immediately. The charge nurse should update the client's plan of care to include interventions
to manage the client following an adverse reaction.
A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2
hr. The client tells the nurse that they are leaving the hospital. After notifying the surgeon, which of the
following actions should the nurse take next?
- correct answer Inform the client about the risks they may encounter by leaving the facility
Using the safety/risk reduction framwork, the nurse should recognize that the greatest risk to this client
is injury from peritonitis; therefore, the first action the nurse should take is to inform the client about
the risks of not receiving treatment.
correct answers 2024\2025 A+ Grade
There has been a community disaster and stable clients must be discharged from a facility to prepare for
the influx of new casualties. A nurse should identify that which of the following clients is safe to
discharge?
- correct answer a client who has multiple sclerosis and reports ataxia
This client is safe to discharge because multiple sclerosis is a chronic disorder and ataxia is an expected
finding.
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the
following clients is the priority?
- correct answer A client who has peripheral vascular disease and has an absent pulse in the right foot
When using the airway, breathing, circulation approach to client care, the nurse determines that the
priority finding is an absent pulse, which indicates no blood flow to the extremity.
A nurse finds that a new IV pump has infused 400 mL of solution over 2 hr when the rate was set at 100
mL/hr. After notifying the provider and verifying that the pump was properly programmed, which of the
following is the nurse's priority?
- correct answer Tag the pump for maintenance and acquire a new pump for the client
The greatest risk is the potential for injury to a client if a nurse uses the pump again before repair;
therefore, the priority for the nurse is to tag the pump for maintenance and acquire a new pump for the
client.
,A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated
to an assistive personnel (AP)? select all that apply
- correct answer ambulating a client who uses a walker, adding thickener to thin liquids on a client's
food tray
Flushing a client's saline lock is incorrect. This is not within the AP's scope of practice.
Ambulating a client who uses a walker is correct. This is within the AP's scope of practice.
Adding thickener to thin liquids on a client's food tray is correct. This is within the AP's scope of practice.
Teaching a client how to use an incentive spirometer is incorrect. This is not within the AP's scope of
practice.
Evaluating a client's gag reflex before mealtime is incorrect. This is not within the AP's scope of practice.
A nurse is caring for a client. Which of the following tasks should the nurse delegate to an assistive
personnel (AP)? select all that apply
- correct answer Place an absorbent pad on the client's bed, report the client's blood pressure to the
nurse, apply barrier cream to the client's buttocks, document the client's vital signs
A charge nurse on a maternal newborn unit is receiving change of shift charge nurse report for a group
of newborns. Which of the following 3 newborns should the charge nurse identify as requiring priority
care? Select 3 newborns the charge nurse should identify as priority.
- correct answer Newborn 5, Newborn 3, Newborn 1
When prioritizing hypotheses using the urgent vs. non-urgent approach to newborn care, the charge
nurse should identify newborn 1, newborn 3, and newborn 5 as requiring priority care based on acuity.
Newborn 1 has manifestations of respiratory distress including tachypnea, grunting, nasal flaring, and
retractions. The charge nurse should further determine if newborn 1 requires prompt interventions.
Newborn 3 presents with manifestations of hypoglycemia including blood glucose below the expected
range, hypothermia, and maternal history of gestational diabetes insulin dependent. Newborn 5 is 23
hours of age and has not had a successful feeding. The newborn additionally has not voided or passed
their first meconium stool. Newborns are expected to have at least one void during the first 24 hours of
life, and one meconium stool with in the first 24 to 48 hours of life. While newborns are sleepier during
the first 48 hours after birth, the newborn should be awoken for feedings at least every 3 hours. These
finding indicate that further intervention by the nurse is needed.
, A nurse manager is assessing incident reports for the unit. Which of the following client's medical
records indicate professional negligence? Select 2 clients that the nurse manager should recognize have
charts that indicate professional negligence.
- correct answer Client 4, Client 5
When recognizing cues, the nurse should identify client 4 and client 5 have medical records that indicate
instances of professional negligence. Professional negligence occurs when an individual with
professional training fails to practice at the level expected of their profession and harm is caused to a
client. For professional negligence to occur there must be a correlation between the nurse's actions and
the harm that came to the client. In client 4's medical record, the nurse failed to administer the client's
prescribed antiseizure medication within the indicated time frame and the client experienced a seizure.
In client scenario 5's medical record, the nurse administered the client's medications outside the
parameters indicated on the prescription and the client experienced syncope and sustained an injury.
The nurse should identify these two client scenarios as instances of professional negligence.
A charge nurse is assisting with the care of a client. Which of the following findings should the charge
nurse identify that the client is experiencing an adverse reaction and requires notification of provider
and updating the client's plan of care? Select 6 findings that indicate that client is having an adverse
reaction.
- correct answer blood pressure, temperature, heart rate, respiratory rate, pain level, report by the
client
When evaluating outcomes, the nurse should identify hypotension, an increase in temperature, heart
rate, and respiratory rate along with reports of abdominal and flank pain as a 6 on a pain scale from 0 to
10 and client report of short of breath and chills can indicate the client is experiencing an acute
hemolytic reaction to the blood transfusion. The nurse should stop the transfusion and notify the client's
provider immediately. The charge nurse should update the client's plan of care to include interventions
to manage the client following an adverse reaction.
A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2
hr. The client tells the nurse that they are leaving the hospital. After notifying the surgeon, which of the
following actions should the nurse take next?
- correct answer Inform the client about the risks they may encounter by leaving the facility
Using the safety/risk reduction framwork, the nurse should recognize that the greatest risk to this client
is injury from peritonitis; therefore, the first action the nurse should take is to inform the client about
the risks of not receiving treatment.
