NSG 444A Exam 3 V3 | NSG 444A Transition to
Practice | Actual Q&A with Rationale (NSG444A
Exam 3) | Grand Canyon University
1. A charge nurse is preparing the daily assignments for a medical-surgical unit. Which of the
following tasks should be prioritized for immediate action to ensure patient safety and
effective care delivery? Select all that apply.
A. Assess a patient who recently returned from surgery and has a heart rate of 120 bpm.
B. Administer routine daily multivitamins to a stable patient awaiting discharge.
C. Evaluate a patient reporting sudden onset of chest pain and shortness of breath.
D. Perform a scheduled dressing change for a chronic pressure ulcer.
E. Monitor a patient whose oxygen saturation has dropped from 96% to 88% on room air.
F. Document the intake and output for a patient who is currently sleeping.
Correct Answer: A, C, E
Explanation: Prioritization in nursing often follows the ABC (Airway, Breathing,
Circulation) framework and the assessment of acute versus chronic conditions. Patients
with sudden physiological changes such as tachycardia post-surgery, chest pain, or a
significant drop in oxygen saturation require immediate intervention to prevent further
deterioration. Routine tasks like documenting I&Os for a sleeping patient or administering
non-urgent vitamins should be deferred until critical needs are met.
,2. A nurse manager is utilizing a democratic leadership style to implement a new evidence-
based practice protocol. Which action by the manager best demonstrates this leadership
approach?
A. Making the decision independently and informing the staff of the new rules.
B. Threatening disciplinary action for those who do not comply with the changes.
C. Giving no direction and letting the staff handle the change as they see fit.
D. Allowing the staff to vote on the specific methods used to implement the protocol.
Correct Answer: D
Explanation: Democratic leadership involves collaborative decision-making and
encourages staff participation in the planning process. This style fosters a sense of
ownership among team members and can improve morale and compliance with new
protocols. By allowing a vote, the manager values the input of the frontline nurses who will
be directly affected by the change.
3. Which ethical principle is being applied when a nurse ensures that a patient receives all the
information necessary to provide informed consent for a surgical procedure?
A. Autonomy
B. Beneficence
C. Justice
D. Non-maleficence
,Correct Answer: A
Explanation: Autonomy refers to the right of the patient to make their own decisions
regarding their healthcare. Providing full information ensures that the patient’s choice is
truly informed and self-directed. This principle respects the individual’s independence and
personal values in the clinical setting.
4. A registered nurse (RN) is delegating tasks to a Licensed Practical Nurse (LPN). According to
the Nurse Practice Act and standard delegation principles, which task is most appropriate for
the LPN?
A. Administering a scheduled subcutaneous insulin injection to a stable patient.
B. Developing a comprehensive plan of care for a patient with multiple comorbidities.
C. Administering an intravenous bolus of a high-alert cardiac medication.
D. Performing the initial admission assessment on a complex trauma patient.
Correct Answer: A
Explanation: LPNs are generally qualified to administer medications and care for stable
patients under the supervision of an RN. Initial assessments and the development of the
primary nursing care plan are responsibilities that require the advanced clinical judgment
of the RN. High-alert IV medications typically fall outside the standard scope of practice for
an LPN in many jurisdictions without specific certification.
, 5. A nurse is reviewing the elements of professional negligence. Which of the following must
be proven for a malpractice claim to be successful? Select all that apply.
A. The nurse had a duty to provide care to the patient.
B. The nurse followed all facility protocols and standards of care.
C. There was a breach of duty by the nurse.
D. The patient suffered actual injury or damages.
E. There is a direct causal link between the breach of duty and the injury.
Correct Answer: A, C, D, E
Explanation: To prove professional negligence or malpractice, four specific elements must
be established: duty, breach of duty, causation, and damages. If the nurse followed all
standards of care, a breach of duty did not occur, and a malpractice claim would likely fail.
Legal success requires showing that the nurse’s deviation from accepted practice directly
resulted in harm to the patient.
6. A nurse is using the SBAR communication tool to report a change in patient status to a
physician. Which statement represents the ‘Background’ component?
A. ‘The patient is experiencing increased respiratory distress.’
B. ‘I recommend that we start the patient on oxygen at 2 liters per nasal cannula.’
C. ‘The patient was admitted two days ago with a diagnosis of heart failure.’
D. ‘The current vitals are BP 140/90, HR 110, and RR 28.’
Practice | Actual Q&A with Rationale (NSG444A
Exam 3) | Grand Canyon University
1. A charge nurse is preparing the daily assignments for a medical-surgical unit. Which of the
following tasks should be prioritized for immediate action to ensure patient safety and
effective care delivery? Select all that apply.
A. Assess a patient who recently returned from surgery and has a heart rate of 120 bpm.
B. Administer routine daily multivitamins to a stable patient awaiting discharge.
C. Evaluate a patient reporting sudden onset of chest pain and shortness of breath.
D. Perform a scheduled dressing change for a chronic pressure ulcer.
E. Monitor a patient whose oxygen saturation has dropped from 96% to 88% on room air.
F. Document the intake and output for a patient who is currently sleeping.
Correct Answer: A, C, E
Explanation: Prioritization in nursing often follows the ABC (Airway, Breathing,
Circulation) framework and the assessment of acute versus chronic conditions. Patients
with sudden physiological changes such as tachycardia post-surgery, chest pain, or a
significant drop in oxygen saturation require immediate intervention to prevent further
deterioration. Routine tasks like documenting I&Os for a sleeping patient or administering
non-urgent vitamins should be deferred until critical needs are met.
,2. A nurse manager is utilizing a democratic leadership style to implement a new evidence-
based practice protocol. Which action by the manager best demonstrates this leadership
approach?
A. Making the decision independently and informing the staff of the new rules.
B. Threatening disciplinary action for those who do not comply with the changes.
C. Giving no direction and letting the staff handle the change as they see fit.
D. Allowing the staff to vote on the specific methods used to implement the protocol.
Correct Answer: D
Explanation: Democratic leadership involves collaborative decision-making and
encourages staff participation in the planning process. This style fosters a sense of
ownership among team members and can improve morale and compliance with new
protocols. By allowing a vote, the manager values the input of the frontline nurses who will
be directly affected by the change.
3. Which ethical principle is being applied when a nurse ensures that a patient receives all the
information necessary to provide informed consent for a surgical procedure?
A. Autonomy
B. Beneficence
C. Justice
D. Non-maleficence
,Correct Answer: A
Explanation: Autonomy refers to the right of the patient to make their own decisions
regarding their healthcare. Providing full information ensures that the patient’s choice is
truly informed and self-directed. This principle respects the individual’s independence and
personal values in the clinical setting.
4. A registered nurse (RN) is delegating tasks to a Licensed Practical Nurse (LPN). According to
the Nurse Practice Act and standard delegation principles, which task is most appropriate for
the LPN?
A. Administering a scheduled subcutaneous insulin injection to a stable patient.
B. Developing a comprehensive plan of care for a patient with multiple comorbidities.
C. Administering an intravenous bolus of a high-alert cardiac medication.
D. Performing the initial admission assessment on a complex trauma patient.
Correct Answer: A
Explanation: LPNs are generally qualified to administer medications and care for stable
patients under the supervision of an RN. Initial assessments and the development of the
primary nursing care plan are responsibilities that require the advanced clinical judgment
of the RN. High-alert IV medications typically fall outside the standard scope of practice for
an LPN in many jurisdictions without specific certification.
, 5. A nurse is reviewing the elements of professional negligence. Which of the following must
be proven for a malpractice claim to be successful? Select all that apply.
A. The nurse had a duty to provide care to the patient.
B. The nurse followed all facility protocols and standards of care.
C. There was a breach of duty by the nurse.
D. The patient suffered actual injury or damages.
E. There is a direct causal link between the breach of duty and the injury.
Correct Answer: A, C, D, E
Explanation: To prove professional negligence or malpractice, four specific elements must
be established: duty, breach of duty, causation, and damages. If the nurse followed all
standards of care, a breach of duty did not occur, and a malpractice claim would likely fail.
Legal success requires showing that the nurse’s deviation from accepted practice directly
resulted in harm to the patient.
6. A nurse is using the SBAR communication tool to report a change in patient status to a
physician. Which statement represents the ‘Background’ component?
A. ‘The patient is experiencing increased respiratory distress.’
B. ‘I recommend that we start the patient on oxygen at 2 liters per nasal cannula.’
C. ‘The patient was admitted two days ago with a diagnosis of heart failure.’
D. ‘The current vitals are BP 140/90, HR 110, and RR 28.’
