Practice – Actual Questions & Answers
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Question 1: The nurse is caring for the following assigned clients who are 24 hours
postoperative. The nurse performed a change-of-shift assessment 4 hours ago. Which of
the following changes in client condition should the nurse identify as a priority?
A. The client who reports an increased pain level of 8 on a scale of 0 to 10 after receiving
an opioid analgesic
B. The client who reports nausea after receiving prescribed antibiotics
C. The client whose dressing has a small amount of new serosanguineous drainage
D. The client who has voided 200 mL in the last 4 hours
Answer: A. The client who reports an increased pain level of 8 on a scale of 0 to 10
after receiving an opioid analgesic
Rationale: Unrelieved or increasing pain after opioids may signal complications such
as hemorrhage, compartment syndrome, or anastomotic leak. This change from
baseline is the most concerning and needs prompt evaluation .
Question 2: The nurse preceptor is teaching a newly hired nurse about legal principles
when providing client care. Which of the following situations should the nurse preceptor
use as an example of malpractice?
A. A nurse documents care at the end of the shift instead of in real time
B. A nurse delays administering a routine oral medication by 30 minutes
C. A client who is competent refuses an antidepressant medication. The nurse dissolves
the medication in food and administers it to the client without the client's knowledge
D. A nurse forgets to orient a new client to the call-bell system
Answer: C. A client who is competent refuses an antidepressant medication. The
nurse dissolves the medication in food and administers it to the client without the
client's knowledge
,Rationale: Giving medication against a competent client's wishes and disguising it
violates autonomy, informed consent, and constitutes battery and malpractice,
because harm can result from this intentional deception .
Question 3: The charge nurse is assigning staff to patients on a medical-surgical unit.
Which patient should be assigned to the LPN?
A. A patient with newly diagnosed diabetic ketoacidosis on an insulin drip
B. A patient with pneumonia who is hemodynamically stable and requires scheduled IV
antibiotics
C. A patient post-cardiac arrest requiring frequent neurological assessments
D. A patient with an epidural catheter for post-op pain management
Answer: B. A patient with pneumonia who is hemodynamically stable and requires
scheduled IV antibiotics
Rationale: LPNs can care for stable patients with predictable outcomes and perform
tasks like administering IV antibiotics to stable patients. Unstable patients, those
requiring frequent assessments, or those with complex titratable drips require an RN .
Question 4: An RN delegates a UAP to obtain vital signs on a patient who is 24 hours
post-liver biopsy. Which instruction by the RN is most appropriate?
A. "Take the blood pressure, and I will assess the patient myself afterward."
B. "Get the vitals and let me know what they are when you're done."
C. "Take the vitals; if they are abnormal, retake them in 15 minutes."
D. "You do not need to take vitals on that patient; I will do it myself."
Answer: D. "You do not need to take vitals on that patient; I will do it myself."
Rationale: A patient post-liver biopsy has a high risk of bleeding. The RN must perform
the first set of post-procedure vital signs to establish a baseline and assess for
complications .
, Question 5: The nurse observes a UAP applying restraints to a confused patient who is
pulling at their IV line without an order. Which action should the nurse take FIRST?
A. Report the UAP to the state board of nursing
B. Remove the restraints immediately and assess the patient
C. Sign off on the UAP's actions as a "verbal order"
D. Ignore the situation to avoid conflict with the UAP
Answer: B. Remove the restraints immediately and assess the patient
Rationale: A UAP cannot apply restraints independently; this requires an RN
assessment and a provider's order. The nurse must prioritize patient safety by removing
the restraints immediately. This is also a form of false imprisonment .
Question 6: When delegating tasks to a float RN from a postpartum unit who is
assigned to the medical-surgical unit for the day, the charge nurse should:
A. Assign the float RN the most complex, unstable patient to challenge their skills
B. Assign the float RN stable patients with predictable outcomes, similar to an LPN
assignment
C. Ask the float RN to complete all admission assessments for new patients
D. Have the float RN hang blood products for a patient with active gastrointestinal
bleeding
Answer: B. Assign the float RN stable patients with predictable outcomes, similar
to an LPN assignment
Rationale: A float nurse is often unfamiliar with the specific unit's routines and patient
acuity. Treating the assignment as a "LPN-level assignment" (stable patients, no initial
assessments) ensures patient safety while the nurse orients to the unit .
Question 7: A nurse on a busy telemetry unit is the only RN for 6 patients and has one
UAP. Which task is most appropriate to delegate to the UAP?
A. Emptying a patient's Foley catheter drainage bag and recording the output
B. Assessing a patient who just returned from the cardiac catheterization lab