RN Leadership– Comprehensive Practice Questions with Correct Answers and Rationales
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.
A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the
following actions should the nurse plan to take? - correct answer Inform the assistive personnel
(AP) of the client's weight-bearing status
APs can assist clients with ambulation in most cases with appropriate delegation from the
nurse. The nurse should inform the AP of postoperative prescriptions for weight-bearing as part
of safe care delegation.
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.
A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the
following actions should the nurse plan to take? - correct answer Inform the assistive personnel
(AP) of the client's weight-bearing status
APs can assist clients with ambulation in most cases with appropriate delegation from the
nurse. The nurse should inform the AP of postoperative prescriptions for weight-bearing as part
of safe care delegation.
