NUR283 COMPREHENSIVE FINAL EXAM: PRIORITY &
DELEGATION QUESTIONS COMPLETE WITH 100%
VERIFIED ANSWERS AND RATIONALES
Question 1
A nurse on a medical-surgical unit is delegating tasks to unlicensed assistive
personnel (UAP). Which of the following delegated tasks requires follow-up by the
charge nurse?
A. Assisting a client who had a paracentesis 2 hours ago to get out of bed for the
first time.
B. Measuring the vital signs of a client with a stable fracture.
C. Providing a bed bath to a client with generalized weakness.
D. Ambulating a client who has been walking independently for 2 days.
Correct Answer: A
Rationale: Any time a client is performing an activity for the first time after a
procedure such as a paracentesis, the registered nurse must perform the initial
assessment and ambulation. This allows the RN to evaluate for complications
including dizziness, bleeding, or orthostatic hypotension. Delegating this task to
UAP would require follow-up by the charge nurse.
Question 2
A nurse is prioritizing patient care after a change of shift report. The nurse should
first plan to see the patient who:
A. Had a cholecystectomy 6 hours ago and reports incisional pain of 4 on a 0 to 10
scale.
B. Had an endoscopic retrograde cholangiopancreatography 30 minutes ago and is
,reporting difficulty swallowing.
C. Is scheduled for discharge in one hour and needs discharge teaching.
D. Has a prescription for a routine morning blood draw.
Correct Answer: B
Rationale: Difficulty swallowing following an endoscopic retrograde
cholangiopancreatography (ERCP) indicates a potential airway or esophageal
complication. This finding relates to the airway, breathing, and circulation (ABC)
framework, making it the highest priority for immediate assessment.
Question 3
The nurse working on the mother-baby unit has become aware of the following
client situations. Which client should the nurse initially assess?
A. A primipara who is 2 hours postpartum and reports perineal discomfort.
B. A mother who is requesting help with breastfeeding for the first time.
C. A neonate who is 4 hours old, whose resting heart rate is 95 beats per minute.
D. A 24-hour-old newborn who has not yet passed meconium.
Correct Answer: C
Rationale: The normal resting heart rate for a newborn is 120 to 140 beats per
minute. A heart rate of 95 beats per minute is bradycardic in a neonate and may
indicate hypoxemia, sepsis, or a cardiac abnormality. This abnormal finding
requires initial assessment.
Question 4
A nurse working on a medical-surgical unit has just received a handoff report on
the following clients. The nurse should first plan to assess the client who has:
A. Chronic obstructive pulmonary disease and an oxygen saturation of 89% on
room air.
B. Diabetes mellitus and a blood glucose level of 140 mg/dL.
C. Hypertension and a blood pressure of 142/90 mm Hg.
,D. Acute pancreatitis and is reporting the development of pain on deep
inspiration.
Correct Answer: D
Rationale: In a client with acute pancreatitis, new onset pain on deep inspiration
can indicate pleural effusion, atelectasis, or the development of a pancreatic
pseudocyst that is irritating the diaphragm. These complications can lead to
respiratory compromise if not caught early, making this the priority for
assessment.
Question 5
The nurse working on a pediatric unit is caring for the following children who have
been admitted in the past 12 hours. It would be a priority goal for the nurse to
initiate an interdisciplinary conference for the child who:
A. Is a 5 year old with diagnosed cystic fibrosis at birth and has been hospitalized 4
times in the past 2 months.
B. Is a 2 year old with a first-time urinary tract infection who is now afebrile.
C. Is an 8 year old with stable asthma who is being discharged tomorrow.
D. Is a 10 year old with a simple arm fracture.
Correct Answer: A
Rationale: The child with cystic fibrosis who has been hospitalized four times in
two months has complex, chronic health needs requiring coordination of multiple
disciplines including pulmonology, nutrition, respiratory therapy, physical therapy,
social work, and child life services. Frequent hospitalizations indicate that current
management is insufficient, making interdisciplinary collaboration the priority.
Question 6
The nurse working in the emergency department has received the following
prescriptions for a newly admitted client. Which prescription should the nurse
implement first?
, A. Obtain a chest x-ray.
B. Draw blood for a complete blood count and basic metabolic panel.
C. Administer an oral dose of acetaminophen for a temperature of 101.2°F.
D. Initiate IV sodium chloride and potassium chloride for a client admitted with
diarrhea and dehydration who has a serum potassium level of 2.9 mEq/L.
Correct Answer: D
Rationale: A serum potassium level of 2.9 mEq/L is critically low and places the
client at risk for life-threatening cardiac dysrhythmias including ventricular
tachycardia or fibrillation. Correcting this electrolyte imbalance with intravenous
replacement is the priority intervention.
Question 7
A nurse is working in a community health clinic assessing clients who are waiting
to be seen. Which client should the nurse have the primary health care provider
see first?
A. A 57 year old with Graves disease who has a temperature of 100.5°F.
B. A 45 year old with well-controlled hypertension here for a medication refill.
C. A 30 year old requesting a pregnancy test.
D. A 60 year old with osteoarthritis here for a routine follow-up.
Correct Answer: A
Rationale: In a client with Graves disease, fever can indicate thyroid storm, a life-
threatening complication characterized by hyperthermia, tachycardia, and altered
mental status. This client requires immediate provider evaluation to rule out this
endocrine emergency.
Question 8
A nurse is working on a pediatric cardiac unit reviewing the telemetry monitors for
assigned clients. Which client should the nurse initially plan to assess?
A. A 2 year old toddler who is walking in the hallway and has a heart rate of 160
DELEGATION QUESTIONS COMPLETE WITH 100%
VERIFIED ANSWERS AND RATIONALES
Question 1
A nurse on a medical-surgical unit is delegating tasks to unlicensed assistive
personnel (UAP). Which of the following delegated tasks requires follow-up by the
charge nurse?
A. Assisting a client who had a paracentesis 2 hours ago to get out of bed for the
first time.
B. Measuring the vital signs of a client with a stable fracture.
C. Providing a bed bath to a client with generalized weakness.
D. Ambulating a client who has been walking independently for 2 days.
Correct Answer: A
Rationale: Any time a client is performing an activity for the first time after a
procedure such as a paracentesis, the registered nurse must perform the initial
assessment and ambulation. This allows the RN to evaluate for complications
including dizziness, bleeding, or orthostatic hypotension. Delegating this task to
UAP would require follow-up by the charge nurse.
Question 2
A nurse is prioritizing patient care after a change of shift report. The nurse should
first plan to see the patient who:
A. Had a cholecystectomy 6 hours ago and reports incisional pain of 4 on a 0 to 10
scale.
B. Had an endoscopic retrograde cholangiopancreatography 30 minutes ago and is
,reporting difficulty swallowing.
C. Is scheduled for discharge in one hour and needs discharge teaching.
D. Has a prescription for a routine morning blood draw.
Correct Answer: B
Rationale: Difficulty swallowing following an endoscopic retrograde
cholangiopancreatography (ERCP) indicates a potential airway or esophageal
complication. This finding relates to the airway, breathing, and circulation (ABC)
framework, making it the highest priority for immediate assessment.
Question 3
The nurse working on the mother-baby unit has become aware of the following
client situations. Which client should the nurse initially assess?
A. A primipara who is 2 hours postpartum and reports perineal discomfort.
B. A mother who is requesting help with breastfeeding for the first time.
C. A neonate who is 4 hours old, whose resting heart rate is 95 beats per minute.
D. A 24-hour-old newborn who has not yet passed meconium.
Correct Answer: C
Rationale: The normal resting heart rate for a newborn is 120 to 140 beats per
minute. A heart rate of 95 beats per minute is bradycardic in a neonate and may
indicate hypoxemia, sepsis, or a cardiac abnormality. This abnormal finding
requires initial assessment.
Question 4
A nurse working on a medical-surgical unit has just received a handoff report on
the following clients. The nurse should first plan to assess the client who has:
A. Chronic obstructive pulmonary disease and an oxygen saturation of 89% on
room air.
B. Diabetes mellitus and a blood glucose level of 140 mg/dL.
C. Hypertension and a blood pressure of 142/90 mm Hg.
,D. Acute pancreatitis and is reporting the development of pain on deep
inspiration.
Correct Answer: D
Rationale: In a client with acute pancreatitis, new onset pain on deep inspiration
can indicate pleural effusion, atelectasis, or the development of a pancreatic
pseudocyst that is irritating the diaphragm. These complications can lead to
respiratory compromise if not caught early, making this the priority for
assessment.
Question 5
The nurse working on a pediatric unit is caring for the following children who have
been admitted in the past 12 hours. It would be a priority goal for the nurse to
initiate an interdisciplinary conference for the child who:
A. Is a 5 year old with diagnosed cystic fibrosis at birth and has been hospitalized 4
times in the past 2 months.
B. Is a 2 year old with a first-time urinary tract infection who is now afebrile.
C. Is an 8 year old with stable asthma who is being discharged tomorrow.
D. Is a 10 year old with a simple arm fracture.
Correct Answer: A
Rationale: The child with cystic fibrosis who has been hospitalized four times in
two months has complex, chronic health needs requiring coordination of multiple
disciplines including pulmonology, nutrition, respiratory therapy, physical therapy,
social work, and child life services. Frequent hospitalizations indicate that current
management is insufficient, making interdisciplinary collaboration the priority.
Question 6
The nurse working in the emergency department has received the following
prescriptions for a newly admitted client. Which prescription should the nurse
implement first?
, A. Obtain a chest x-ray.
B. Draw blood for a complete blood count and basic metabolic panel.
C. Administer an oral dose of acetaminophen for a temperature of 101.2°F.
D. Initiate IV sodium chloride and potassium chloride for a client admitted with
diarrhea and dehydration who has a serum potassium level of 2.9 mEq/L.
Correct Answer: D
Rationale: A serum potassium level of 2.9 mEq/L is critically low and places the
client at risk for life-threatening cardiac dysrhythmias including ventricular
tachycardia or fibrillation. Correcting this electrolyte imbalance with intravenous
replacement is the priority intervention.
Question 7
A nurse is working in a community health clinic assessing clients who are waiting
to be seen. Which client should the nurse have the primary health care provider
see first?
A. A 57 year old with Graves disease who has a temperature of 100.5°F.
B. A 45 year old with well-controlled hypertension here for a medication refill.
C. A 30 year old requesting a pregnancy test.
D. A 60 year old with osteoarthritis here for a routine follow-up.
Correct Answer: A
Rationale: In a client with Graves disease, fever can indicate thyroid storm, a life-
threatening complication characterized by hyperthermia, tachycardia, and altered
mental status. This client requires immediate provider evaluation to rule out this
endocrine emergency.
Question 8
A nurse is working on a pediatric cardiac unit reviewing the telemetry monitors for
assigned clients. Which client should the nurse initially plan to assess?
A. A 2 year old toddler who is walking in the hallway and has a heart rate of 160
