NSG 444A Exam 3 V1 | NSG 444A Transition to
Practice | Actual Q&A with Rationale (NSG444A
Exam 3) | Grand Canyon University
1. A charge nurse is observing a newly licensed nurse who is prioritizing care for a group of
clients. Which of the following actions by the new nurse indicates a need for further
teaching?
A. The nurse assesses a client who reports shortness of breath before a client who needs a
routine dressing change.
B. The nurse prepares to administer a scheduled PRN analgesic to a client who is rating
pain as 4 on a scale of 0 to 10 before assessing a client with a new onset of confusion.
C. The nurse checks on a client who is postoperative day 1 and had a stable blood pressure
before helping a client who is being discharged.
D. The nurse monitors the oxygen saturation of a client with pneumonia before
documenting the intake and output of another client.
Correct Answer: B
Explanation: Assessing a client with a new onset of confusion should take priority over
administering a non-urgent PRN medication because it could indicate a physiological crisis
like hypoxia or stroke. Prioritization should follow the ABC (Airway, Breathing, Circulation)
or Maslow’s Hierarchy of Needs framework. The nurse must recognize that neurological
changes often represent acute safety concerns that require immediate intervention.
,2. A nurse manager is discussing the ‘Five Rights of Delegation’ during a staff meeting. Which
of the following elements are included in this framework? (Select All That Apply)
A. Right Task
B. Right Circumstance
C. Right Person
D. Right Direction/Communication
E. Right Supervision/Evaluation
F. Right Salary Adjustment
Correct Answer: ABCDE
Explanation: The five rights of delegation are essential for ensuring patient safety and
professional accountability. These include the right task, right circumstance, right person,
right direction/communication, and right supervision/evaluation. Salary adjustments are
administrative functions unrelated to the clinical delegation process between an RN and
assistive personnel.
3. A nurse is caring for a client who is scheduled for surgery. The client states, ‘I am not sure if
I want to go through with this procedure anymore.’ Which of the following actions should the
nurse take first?
A. Ask the client to explain their concerns about the surgery.
B. Notify the surgeon that the client wishes to cancel the procedure.
,C. Provide the client with a pamphlet detailing the benefits of the surgery.
D. Document the client’s statement in the medical record and continue preoperative prep.
Correct Answer: A
Explanation: The nurse’s first action should be to assess the client’s feelings and concerns
to understand the root of their hesitation. Effective communication allows the nurse to
determine if the client needs more information or is experiencing anxiety. This approach
supports the ethical principle of autonomy and ensures the client’s voice is heard before
escalating the situation to the surgeon.
4. A nurse manager is utilizing Lewin’s Change Theory to implement a new electronic health
record system. During the ‘Unfreezing’ stage, which of the following actions is most
appropriate?
A. Developing a detailed timeline for the transition to the new system.
B. Communicating the reasons why the current system is no longer effective.
C. Providing hands-on training sessions for all staff members.
D. Rewarding staff members who successfully adopt the new workflow.
Correct Answer: B
Explanation: The unfreezing stage involves creating readiness for change by helping
individuals realize that the current status quo is no longer viable. By communicating the
limitations of the old system, the manager builds a sense of urgency and necessity for the
, upcoming change. This stage is critical for overcoming resistance and preparing the
organization for the ‘Moving’ phase.
5. An RN is working with an LPN and a UAP. Which task is most appropriate for the RN to
delegate to the LPN?
A. Administering a scheduled subcutaneous insulin injection to a stable client.
B. Developing the initial plan of care for a client following a stroke.
C. Performing an admission assessment on a client with heart failure.
D. Evaluating the effectiveness of a new IV medication for hypertension.
Correct Answer: A
Explanation: Administering routine medications such as subcutaneous insulin is within
the scope of practice for an LPN in many jurisdictions. Tasks involving assessment,
planning, and evaluation require the advanced clinical judgment of the RN. Delegating a
stable task like insulin administration allows the RN to focus on more complex clinical
decision-making and care coordination.
6. A nurse is faced with an ethical dilemma regarding a client’s end-of-life care. The nurse’s
primary commitment, according to the ANA Code of Ethics, is to:
A. The client, whether an individual, family, group, or community.
B. The healthcare facility’s policy and procedures.
C. The physician’s orders for the plan of care.
Practice | Actual Q&A with Rationale (NSG444A
Exam 3) | Grand Canyon University
1. A charge nurse is observing a newly licensed nurse who is prioritizing care for a group of
clients. Which of the following actions by the new nurse indicates a need for further
teaching?
A. The nurse assesses a client who reports shortness of breath before a client who needs a
routine dressing change.
B. The nurse prepares to administer a scheduled PRN analgesic to a client who is rating
pain as 4 on a scale of 0 to 10 before assessing a client with a new onset of confusion.
C. The nurse checks on a client who is postoperative day 1 and had a stable blood pressure
before helping a client who is being discharged.
D. The nurse monitors the oxygen saturation of a client with pneumonia before
documenting the intake and output of another client.
Correct Answer: B
Explanation: Assessing a client with a new onset of confusion should take priority over
administering a non-urgent PRN medication because it could indicate a physiological crisis
like hypoxia or stroke. Prioritization should follow the ABC (Airway, Breathing, Circulation)
or Maslow’s Hierarchy of Needs framework. The nurse must recognize that neurological
changes often represent acute safety concerns that require immediate intervention.
,2. A nurse manager is discussing the ‘Five Rights of Delegation’ during a staff meeting. Which
of the following elements are included in this framework? (Select All That Apply)
A. Right Task
B. Right Circumstance
C. Right Person
D. Right Direction/Communication
E. Right Supervision/Evaluation
F. Right Salary Adjustment
Correct Answer: ABCDE
Explanation: The five rights of delegation are essential for ensuring patient safety and
professional accountability. These include the right task, right circumstance, right person,
right direction/communication, and right supervision/evaluation. Salary adjustments are
administrative functions unrelated to the clinical delegation process between an RN and
assistive personnel.
3. A nurse is caring for a client who is scheduled for surgery. The client states, ‘I am not sure if
I want to go through with this procedure anymore.’ Which of the following actions should the
nurse take first?
A. Ask the client to explain their concerns about the surgery.
B. Notify the surgeon that the client wishes to cancel the procedure.
,C. Provide the client with a pamphlet detailing the benefits of the surgery.
D. Document the client’s statement in the medical record and continue preoperative prep.
Correct Answer: A
Explanation: The nurse’s first action should be to assess the client’s feelings and concerns
to understand the root of their hesitation. Effective communication allows the nurse to
determine if the client needs more information or is experiencing anxiety. This approach
supports the ethical principle of autonomy and ensures the client’s voice is heard before
escalating the situation to the surgeon.
4. A nurse manager is utilizing Lewin’s Change Theory to implement a new electronic health
record system. During the ‘Unfreezing’ stage, which of the following actions is most
appropriate?
A. Developing a detailed timeline for the transition to the new system.
B. Communicating the reasons why the current system is no longer effective.
C. Providing hands-on training sessions for all staff members.
D. Rewarding staff members who successfully adopt the new workflow.
Correct Answer: B
Explanation: The unfreezing stage involves creating readiness for change by helping
individuals realize that the current status quo is no longer viable. By communicating the
limitations of the old system, the manager builds a sense of urgency and necessity for the
, upcoming change. This stage is critical for overcoming resistance and preparing the
organization for the ‘Moving’ phase.
5. An RN is working with an LPN and a UAP. Which task is most appropriate for the RN to
delegate to the LPN?
A. Administering a scheduled subcutaneous insulin injection to a stable client.
B. Developing the initial plan of care for a client following a stroke.
C. Performing an admission assessment on a client with heart failure.
D. Evaluating the effectiveness of a new IV medication for hypertension.
Correct Answer: A
Explanation: Administering routine medications such as subcutaneous insulin is within
the scope of practice for an LPN in many jurisdictions. Tasks involving assessment,
planning, and evaluation require the advanced clinical judgment of the RN. Delegating a
stable task like insulin administration allows the RN to focus on more complex clinical
decision-making and care coordination.
6. A nurse is faced with an ethical dilemma regarding a client’s end-of-life care. The nurse’s
primary commitment, according to the ANA Code of Ethics, is to:
A. The client, whether an individual, family, group, or community.
B. The healthcare facility’s policy and procedures.
C. The physician’s orders for the plan of care.
