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SECTION 1: MANAGEMENT OF CARE, PRIORITIZATION & DELEGATION (Questions 1–30)
1. A nurse is caring for four clients. Which client should the nurse assess FIRST?
A) A client who is 1 day postoperative with pain rated 6/10
B) A client with COPD who has an O₂ saturation of 88% on room air
C) A client waiting for discharge teaching
D) A client requesting assistance with ambulation
Answer: B
Explanation: Using the ABC framework (Airway, Breathing, Circulation), the client with an O₂ saturation
of 88% on room air is experiencing respiratory compromise and requires immediate assessment. Pain
(A) is important but not lifethreatening. Discharge teaching (C) and ambulation assistance (D) are lower
priorities.
2. A nurse manager is reviewing informed consent with staff. Which statement indicates understanding?
A) "The nurse is responsible for explaining the procedure."
B) "A witness signature confirms the client gave voluntary consent."
C) "Informed consent is only required for surgical procedures."
D) "A family member can sign for any adult client."
Answer: B
Explanation: The witness signature confirms that the client signed voluntarily and appeared competent.
The provider (not the nurse) is responsible for explaining the procedure. Informed consent is required
,for many procedures, not just surgery. A family member cannot sign for any adult client without legal
authorization.
3. A charge nurse is assigning clients. Which client should be assigned to a newly licensed RN?
A) Client with a chest tube and continuous bubbling
B) Client with newonset atrial fibrillation on a heparin drip
C) Client with stable pneumonia receiving oral antibiotics
D) Client with a tracheostomy requiring suctioning q2h
Answer: C
Explanation: Newly licensed RNs should care for stable, predictable clients with routine care needs.
Clients with chest tubes (A), unstable cardiac conditions (B), or tracheostomies (D) require more
experienced nurses.
4. A nurse is assisting with mass casualty triage after an explosion. Which client should be identified as
the priority?
A) Client with massive head trauma
B) Client with fullthickness burns to face and trunk
C) Client with indications of hypovolemic shock
D) Client with an open fracture of the lower extremity
Answer: C
Explanation: In mass casualty triage, clients with potentially survivable but critical conditions (e.g.,
hypovolemic shock) are prioritized over those with nonsurvivable injuries (A) or stable conditions (D).
5. A nurse is caring for a client who is in restraints. A verbal prescription was obtained. Which action
should the nurse take?
A) Implement restraints immediately
B) Document the verbal order within 24 hours
C) Request a renewal of the prescription every 8 hours
D) Obtain a written order within 1 hour
,Answer: C
Explanation: Restraint orders must be renewed every 8 hours for adults. The nurse should also obtain a
written order as soon as possible.
6. A nurse is reviewing incident reports. Which statement by a staff member indicates understanding of
their purpose?
A) "The incident report is used to discipline the staff member involved."
B) "The incident report is used to identify risks and improve patient safety."
C) "The incident report should be documented in the patient's chart."
D) "The incident report should be completed only if the patient is injured."
Answer: B
Explanation: Incident reports are used to identify risks and improve patient safety, not to discipline staff.
They should not be documented in the patient's chart.
7. A nurse is prioritizing care using Maslow's Hierarchy of Needs. Which client should be seen FIRST?
A) A client experiencing chest pain
B) A client with low selfesteem
C) A client who feels isolated from family
D) A client needing help with bathing
Answer: A
Explanation: Chest pain is a physiological need (airway, breathing, circulation) and takes priority over
psychosocial needs (B, C) and activities of daily living (D).
8. A nurse is delegating tasks to an LPN/LVN. Which task is appropriate to delegate?
A) Administering IV push medications
B) Performing an initial assessment
C) Administering oral medications to a stable client
, D) Developing a care plan
Answer: C
Explanation: LPNs/LVNs can administer oral medications to stable clients. IV push medications (A), initial
assessments (B), and care plan development (D) are RN responsibilities.
9. A nurse is caring for a client who speaks a different language. Which action should the nurse take?
A) Ask a family member to interpret
B) Use a certified medical interpreter
C) Speak loudly and slowly
D) Use gestures to communicate
Answer: B
Explanation: A certified medical interpreter should be used to ensure accurate communication. Family
members should not interpret due to potential errors and confidentiality concerns.
10. A nurse is preparing to administer a blood transfusion. Which action is the highest priority before
initiating the transfusion?
A) Obtain baseline vital signs
B) Prime the IV tubing with 0.9% sodium chloride
C) Verify the client's identity and blood product with another nurse
D) Assess the client's lung sounds
Answer: C
Explanation: Verifying client identity and blood product with another nurse is the highest priority to
prevent a hemolytic transfusion reaction. Baseline vitals (A) and lung sounds (D) are important but
secondary to verification.
11. A nurse manager is implementing a new evidencebased practice protocol. Which leadership style is
most effective when staff are highly competent and motivated?
A) Autocratic