PN NCLEX- Board Exam Safe and Effective Care
Environment
**1. Coordinated Care: Delegation** A charge nurse is delegating
tasks. Which task is appropriate to delegate to unlicensed assistive
personnel (UAP)?
A. Performing a focused respiratory assessment on a client with new-
onset dyspnea.
B. Assisting a stable post-op client with ambulation to the hallway.
C. Educating a client with diabetes about foot care.
D. Titrating oxygen flow rate based on oxygen saturation readings.
**Correct Answer: B**
**Rationale:** The Five Rights of Delegation must be followed.
Assisting a stable client with ambulation is within the UAP’s scope of
practice. Options A, C, and D all require nursing judgment and
assessment, and cannot be delegated to UAP.
**2. Coordinated Care: Client Rights** The nurse is planning a staff
education program about client privacy. Which scenario is a violation
of client privacy?
A. Discussing with a UAP that their assigned client will require a
smaller condom catheter.
B. Sharing a client's blood alcohol level with the police officer who
brought them to the ED.
C. Responding to the call light of a client assigned to another nurse.
D. Allowing a nursing student assigned to the client to review their
medical record.
, **Correct Answer: B**
**Rationale:** Sharing a client's protected health information (PHI)
with law enforcement without a warrant or specific legal exception is
a violation of HIPAA and client privacy .
**3. Safety and Infection Control: Transmission-Based Precautions**
A nurse is caring for a client with *Clostridioides difficile* (C. diff).
Which PPE should the nurse don before entering the room?
A. Surgical mask and gloves.
B. N95 respirator, gown, and gloves.
C. Gown and gloves.
D. Gown, gloves, and surgical mask.
**Correct Answer: C**
**Rationale:** *C. diff* is transmitted via the fecal-oral route,
requiring Contact Precautions, which necessitate a gown and gloves.
Alcohol-based hand rubs are ineffective against *C. diff* spores; soap
and water must be used for hand hygiene after care.
**4. Safety and Infection Control: Emergency Response** The nurse
and a UAP are caring for assigned clients. Which task is appropriate
for the nurse to assign to the UAP?
A. Assisting a client with atrial fibrillation to shower.
B. Checking the ability of a client to swallow water after a TEE.
C. Observing a client with dysphagia beginning a thickened liquid
diet.
D. Transporting a client with respiratory distress to radiology.
**Correct Answer: A**
Environment
**1. Coordinated Care: Delegation** A charge nurse is delegating
tasks. Which task is appropriate to delegate to unlicensed assistive
personnel (UAP)?
A. Performing a focused respiratory assessment on a client with new-
onset dyspnea.
B. Assisting a stable post-op client with ambulation to the hallway.
C. Educating a client with diabetes about foot care.
D. Titrating oxygen flow rate based on oxygen saturation readings.
**Correct Answer: B**
**Rationale:** The Five Rights of Delegation must be followed.
Assisting a stable client with ambulation is within the UAP’s scope of
practice. Options A, C, and D all require nursing judgment and
assessment, and cannot be delegated to UAP.
**2. Coordinated Care: Client Rights** The nurse is planning a staff
education program about client privacy. Which scenario is a violation
of client privacy?
A. Discussing with a UAP that their assigned client will require a
smaller condom catheter.
B. Sharing a client's blood alcohol level with the police officer who
brought them to the ED.
C. Responding to the call light of a client assigned to another nurse.
D. Allowing a nursing student assigned to the client to review their
medical record.
, **Correct Answer: B**
**Rationale:** Sharing a client's protected health information (PHI)
with law enforcement without a warrant or specific legal exception is
a violation of HIPAA and client privacy .
**3. Safety and Infection Control: Transmission-Based Precautions**
A nurse is caring for a client with *Clostridioides difficile* (C. diff).
Which PPE should the nurse don before entering the room?
A. Surgical mask and gloves.
B. N95 respirator, gown, and gloves.
C. Gown and gloves.
D. Gown, gloves, and surgical mask.
**Correct Answer: C**
**Rationale:** *C. diff* is transmitted via the fecal-oral route,
requiring Contact Precautions, which necessitate a gown and gloves.
Alcohol-based hand rubs are ineffective against *C. diff* spores; soap
and water must be used for hand hygiene after care.
**4. Safety and Infection Control: Emergency Response** The nurse
and a UAP are caring for assigned clients. Which task is appropriate
for the nurse to assign to the UAP?
A. Assisting a client with atrial fibrillation to shower.
B. Checking the ability of a client to swallow water after a TEE.
C. Observing a client with dysphagia beginning a thickened liquid
diet.
D. Transporting a client with respiratory distress to radiology.
**Correct Answer: A**
