Practice Questions with ANSWERs & Rationales
SECTION 1: SAFE & EFFECTIVE CARE ENVIRONMENT (Questions 1–25)
Delegation, Assignment, and Supervision
1. A nurse is delegating tasks to an assistive personnel (AP) on a medical-surgical unit. Which task is
appropriate to delegate to the AP?
A. Assessing a postoperative client's surgical incision for signs of infection
B. Teaching a newly diagnosed diabetic client how to use a glucometer
C. Ambulating a stable client who is 1 day post-op after a total knee replacement
D. Evaluating the effectiveness of pain medication given 30 minutes ago
ANSWER: C
Rationale: APs can perform tasks that are routine, do not require nursing judgment, and have
predictable outcomes. Ambulating a stable postoperative client falls within AP scope of practice.
Assessment, teaching, and evaluation require licensed nursing judgment and cannot be delegated.
2. A nurse on a med-surg unit has received change-of-shift report and will care for 4 clients. Which
client's need may the nurse assign to an assistive personnel (AP)?
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
,B. Reinforcing teaching with a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
ANSWER: C
Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may
delegate to the AP. Feeding a client with aspiration pneumonia requires assessment of swallowing
ability. Teaching and sterile dressing changes require nursing judgment and cannot be delegated.
3. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which
information should the nurse share with the AP? (Select all that apply.)
A. The roommate is up independently
B. The client ambulates with slippers on over antiembolic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain medication 30 minutes ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning
ANSWER: B, C, D
Rationale: When delegating, the nurse must provide specific information about the task, including how
the client ambulates (B, C) and the timing of pain medication (D) to ensure safety. Information about
other clients (A), allergies (E), and dietary intake (F) are not relevant to the specific delegated task of
ambulation.
,4. An RN is making assignments for client care to an LPN at the beginning of the shift. Which assignment
should the LPN question?
A. Assisting a client who is 24 hours post-op to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client admitted on the previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
ANSWER: D
Rationale: The RN is responsible for the PCA pump, including replacing the cartridge and tubing. LPNs
can perform tasks such as incentive spirometry assistance, specimen collection, and suctioning within
their scope of practice.
5. A nurse is preparing an in-service program about delegation. Which elements should she identify as
the "5 rights of delegation"? (Select all that apply.)
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances
, ANSWER: B, C, E
Rationale: The 5 rights of delegation are: right task, right circumstances, right person, right
direction/communication, and right supervision/evaluation. Right client and right time are rights of
medication administration, not delegation.
6. A nurse manager on a med-surg unit is assigning care responsibilities for the oncoming shift. A client is
awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member
should the nurse assign this client?
A. Charge nurse
B. RN
C. LPN
D. AP
ANSWER: B
Rationale: A client returning from surgery requires assessment and establishment of a plan of care. RNs
are responsible for this, especially if the client is potentially unstable.
Legal and Ethical Issues
7. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells the client
she will put a diaper on him if he does not use the urinal more carefully next time. Which tort is the AP
committing?
A. Assault
B. Battery
C. False imprisonment