PNR 207/PNR207 Exam 2 V2 | Transition to PN
Practice - Capstone Q&A with Rationale | Fortis
College
1. A Licensed Practical Nurse (LPN) is planning care for a group of clients. According to the
principles of prioritization, which client should the nurse assess first?
A. A client with diabetes mellitus who has a fasting blood glucose of 150 mg/dL.
B. A client who is 2 days postoperative and reporting a pain level of 4 out of 10.
C. A client scheduled for discharge who needs instructions on wound care.
D. A client with chronic obstructive pulmonary disease (COPD) reporting increased
shortness of breath and an oxygen saturation of 88%.
Correct Answer: D
Explanation: The client with COPD and declining oxygen saturation represents an acute
respiratory issue, which takes priority according to the Airway-Breathing-Circulation
(ABC) framework. While the diabetic client has elevated glucose, it is not immediately life-
threatening. Providing discharge instructions or managing moderate postoperative pain
are important tasks but are secondary to stabilizing a client’s breathing.
2. An LPN is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which task is most
appropriate for the nurse to delegate?
A. Measuring and recording intake and output for a client with heart failure.
B. Performing a sterile dressing change on a central venous line.
,C. Assisting a stable client with ambulation for the first time after surgery.
D. Evaluating the effectiveness of pain medication given to a client.
Correct Answer: A
Explanation: Measuring and recording intake and output is a routine, non-invasive task
that falls within the scope of practice for a UAP. Sterile dressing changes and evaluating
medication effectiveness require the clinical judgment and specialized skills of a licensed
nurse. Ambulation for the first time after surgery requires the nurse’s assessment to ensure
the client is stable and safe to move.
3. The nurse is reviewing the ethical principle of ‘Autonomy.’ Which action by the nurse
demonstrates this principle?
A. Following through on a promise to return to a client’s room in 10 minutes.
B. Administering a prescribed pain medication to alleviate a client’s suffering.
C. Providing the same level of care to all clients regardless of their socioeconomic status.
D. Ensuring a client has all the information needed to make an informed decision about
surgery.
Correct Answer: D
Explanation: Autonomy refers to the right of the client to make their own decisions
regarding their healthcare. By ensuring the client is fully informed, the nurse supports the
client’s self-determination and independent choice. Other principles mentioned include
fidelity (keeping promises), justice (fairness), and beneficence (doing good).
, 4. A nurse is preparing to administer medication and realizes the dosage is higher than the
standard range. What is the most appropriate action for the nurse to take?
A. Administer the dose as ordered because the physician knows the client’s history.
B. Administer a standard dose instead of the ordered dose.
C. Ask another LPN to administer the medication.
D. Contact the prescribing healthcare provider to clarify the order.
Correct Answer: D
Explanation: The nurse has a legal and professional responsibility to clarify any order that
seems unsafe or outside standard parameters. Administering a potentially toxic dose could
result in negligence or malpractice. The nurse should never change a dosage independently
or delegate an unsafe task to a peer.
5. When using the SBAR communication tool, which information should the nurse include in
the ‘Background’ section?
A. The client’s current vital signs and mental status.
B. The client’s medical history, allergies, and recent laboratory results.
C. A description of the current problem or reason for calling.
D. A specific request for a change in the treatment plan.
Correct Answer: B
Practice - Capstone Q&A with Rationale | Fortis
College
1. A Licensed Practical Nurse (LPN) is planning care for a group of clients. According to the
principles of prioritization, which client should the nurse assess first?
A. A client with diabetes mellitus who has a fasting blood glucose of 150 mg/dL.
B. A client who is 2 days postoperative and reporting a pain level of 4 out of 10.
C. A client scheduled for discharge who needs instructions on wound care.
D. A client with chronic obstructive pulmonary disease (COPD) reporting increased
shortness of breath and an oxygen saturation of 88%.
Correct Answer: D
Explanation: The client with COPD and declining oxygen saturation represents an acute
respiratory issue, which takes priority according to the Airway-Breathing-Circulation
(ABC) framework. While the diabetic client has elevated glucose, it is not immediately life-
threatening. Providing discharge instructions or managing moderate postoperative pain
are important tasks but are secondary to stabilizing a client’s breathing.
2. An LPN is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which task is most
appropriate for the nurse to delegate?
A. Measuring and recording intake and output for a client with heart failure.
B. Performing a sterile dressing change on a central venous line.
,C. Assisting a stable client with ambulation for the first time after surgery.
D. Evaluating the effectiveness of pain medication given to a client.
Correct Answer: A
Explanation: Measuring and recording intake and output is a routine, non-invasive task
that falls within the scope of practice for a UAP. Sterile dressing changes and evaluating
medication effectiveness require the clinical judgment and specialized skills of a licensed
nurse. Ambulation for the first time after surgery requires the nurse’s assessment to ensure
the client is stable and safe to move.
3. The nurse is reviewing the ethical principle of ‘Autonomy.’ Which action by the nurse
demonstrates this principle?
A. Following through on a promise to return to a client’s room in 10 minutes.
B. Administering a prescribed pain medication to alleviate a client’s suffering.
C. Providing the same level of care to all clients regardless of their socioeconomic status.
D. Ensuring a client has all the information needed to make an informed decision about
surgery.
Correct Answer: D
Explanation: Autonomy refers to the right of the client to make their own decisions
regarding their healthcare. By ensuring the client is fully informed, the nurse supports the
client’s self-determination and independent choice. Other principles mentioned include
fidelity (keeping promises), justice (fairness), and beneficence (doing good).
, 4. A nurse is preparing to administer medication and realizes the dosage is higher than the
standard range. What is the most appropriate action for the nurse to take?
A. Administer the dose as ordered because the physician knows the client’s history.
B. Administer a standard dose instead of the ordered dose.
C. Ask another LPN to administer the medication.
D. Contact the prescribing healthcare provider to clarify the order.
Correct Answer: D
Explanation: The nurse has a legal and professional responsibility to clarify any order that
seems unsafe or outside standard parameters. Administering a potentially toxic dose could
result in negligence or malpractice. The nurse should never change a dosage independently
or delegate an unsafe task to a peer.
5. When using the SBAR communication tool, which information should the nurse include in
the ‘Background’ section?
A. The client’s current vital signs and mental status.
B. The client’s medical history, allergies, and recent laboratory results.
C. A description of the current problem or reason for calling.
D. A specific request for a change in the treatment plan.
Correct Answer: B
