Exam Format | 180 Q&A | Grade A Study
Material | Pass Guaranteed - A+ Graded
SECTION 1: MANAGEMENT OF CARE (Questions 1-20)
Q1: A nurse is assigning tasks to an assistive personnel (AP) for a group of clients. Which of the following
tasks should the nurse delegate to the AP?
A. Administering oral medications to a stable client
B. Measuring and recording intake and output for a client with a Foley catheter
C. Assessing a postoperative client's incision for signs of infection
D. Teaching a client about diabetic foot care
Correct Answer: B
Rationale: Measuring and recording intake and output is a routine, non-invasive task with predictable
outcomes that falls within the AP scope of practice. This task does not require nursing judgment,
assessment, or teaching skills. Option A is incorrect because medication administration requires nursing
licensure and clinical judgment, regardless of the client's stability. Option C is incorrect because wound
assessment requires nursing knowledge to identify complications and changes in condition. Option D is
incorrect because client teaching requires the nurse to evaluate understanding and adapt teaching
methods, which is outside AP scope.
Q2: A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a blood pressure of 138/88 mm Hg who reports a headache
B. A client with a heart rate of 110/min who is anxious about an upcoming procedure
C. A client with a respiratory rate of 28/min and SpO2 of 88% on room air
D. A client with a temperature of 38.2°C (100.8°F) who has a surgical incision
Correct Answer: C
Rationale: According to the ABCs (Airway, Breathing, Circulation) priority framework, the client with
compromised oxygenation (SpO2 88%, RR 28) requires immediate assessment and intervention. This
represents a life-threatening situation. Option A is incorrect because while the headache needs
,assessment, the vital signs are within acceptable limits and this is not an immediate priority. Option B is
incorrect because tachycardia related to anxiety, while requiring monitoring, is less urgent than
compromised oxygenation. Option D is incorrect because a low-grade fever in a postoperative client,
while requiring monitoring, is not immediately life-threatening.
Q3: A nurse is reviewing the legal aspects of informed consent with a newly licensed practical nurse.
Which of the following statements by the LPN indicates understanding?
A. "I can obtain informed consent for a client undergoing a routine procedure."
B. "The physician is responsible for explaining the risks and benefits of the procedure."
C. "I can witness the client's signature on the consent form if I observed the signing."
D. "Informed consent is not needed for emergency procedures when the client is unconscious."
Correct Answer: C
Rationale: An LPN can serve as a witness to informed consent by observing the client sign the form and
confirming that the signature is voluntary. This is within LPN scope. Option A is incorrect because
obtaining informed consent (explaining risks, benefits, alternatives) is the physician's responsibility;
nurses clarify information but do not obtain consent. Option B is partially correct but incomplete—the
physician explains, but the LPN's role as witness is what demonstrates understanding of the LPN's
specific role. Option D is incorrect because while emergency treatment may proceed without consent
under implied consent doctrine, this statement oversimplifies the legal requirements.
Q4: A nurse is caring for a client who has a new diagnosis of diabetes mellitus. The client asks the nurse
to explain the results of the glycosylated hemoglobin (HbA1c) test. Which of the following responses
should the nurse make?
A. "It measures your blood sugar level from the past 24 hours."
B. "It shows your average blood glucose control over the past 2 to 3 months."
C. "It indicates whether you need insulin therapy."
D. "It tells us if you have type 1 or type 2 diabetes."
Correct Answer: B
Rationale: HbA1c reflects average blood glucose levels over the lifespan of red blood cells
(approximately 120 days), providing a 2-3 month average of glycemic control. Option A is incorrect
because that describes fasting blood glucose or random glucose testing. Option C is incorrect because
insulin therapy decisions are based on multiple factors including glucose levels, symptoms, and clinical
presentation, not HbA1c alone. Option D is incorrect because HbA1c cannot differentiate between type
1 and type 2 diabetes; this requires clinical assessment and additional testing.
,Q5: A nurse is caring for a client who is receiving hospice care. The client's family member asks the
nurse, "How much longer do you think my mother has to live?" Which of the following responses should
the nurse make?
A. "I think she will probably pass within the next 48 hours."
B. "Let's focus on keeping her comfortable rather than predicting the time."
C. "It is difficult to predict exactly, but I can describe the signs that indicate the end is near."
D. "You should talk to the physician about that question."
Correct Answer: C
Rationale: This response provides honest, therapeutic communication while offering education about
end-of-life signs, which empowers the family and maintains trust. Option A is incorrect because
predicting exact timeframes is inaccurate and can destroy trust if incorrect. Option B is incorrect
because while comfort is important, it dismisses the family's legitimate need for information and does
not address their anxiety. Option D is incorrect because it deflects responsibility when the nurse, who
spends the most time with the client, can provide valuable information about the dying process.
Q6: A nurse is reviewing advance directives with a client. Which of the following statements by the client
indicates a need for further teaching?
A. "My durable power of attorney for health care can make decisions if I become unable."
B. "A living will specifies what treatments I want or don't want at the end of life."
C. "Once I sign an advance directive, I cannot change my mind later."
D. "My family cannot override my advance directive if I am competent."
Correct Answer: C
Rationale: Advance directives can be revoked or modified at any time while the client is competent; this
statement indicates a misunderstanding requiring correction. Option A is correct—a durable power of
attorney designates a surrogate decision-maker. Option B is correct—a living will documents treatment
preferences. Option D is correct—when competent, the client's current wishes supersede family
preferences and prior directives.
Q7: A nurse is acting as a client advocate for an older adult client who is considering transfer to a long-
term care facility. Which of the following actions demonstrates advocacy?
A. Convincing the client to stay in the hospital until fully recovered
B. Providing information about different facilities and helping the client visit them
C. Telling the client which facility the nurse thinks is best
, D. Asking the client's family to make the decision for the client
Correct Answer: B
Rationale: Advocacy involves supporting the client's autonomous decision-making by providing
information and facilitating their ability to make informed choices. Option A is incorrect because it
imposes the nurse's preference rather than supporting client autonomy. Option C is incorrect because
while the nurse can offer opinions, true advocacy empowers the client's own decision-making process.
Option D is incorrect because it removes decision-making authority from the client unless the client
specifically requests family involvement.
Q8: A nurse is supervising a newly hired AP who is providing care for a group of clients. Which of the
following observations requires immediate intervention by the nurse?
A. The AP assists a client to the bathroom using a gait belt
B. The AP reports a client's blood pressure reading of 142/88 to the nurse
C. The AP applies a condom catheter to a male client without checking for proper fit
D. The AP documents a client's intake and output on the electronic record
Correct Answer: C
Rationale: Applying a condom catheter without ensuring proper fit can cause constriction injury,
impaired circulation, and skin breakdown—this requires immediate intervention to prevent harm.
Option A is correct AP performance. Option B is appropriate—the AP should report abnormal findings to
the nurse. Option D is within AP scope. The safety risk in Option C makes it the priority for intervention.
Q9: A nurse is caring for a client who asks about the Health Insurance Portability and Accountability Act
(HIPAA). Which of the following explanations should the nurse provide?
A. "HIPAA ensures that you can receive emergency care regardless of ability to pay."
B. "HIPAA protects the privacy and security of your health information."
C. "HIPAA guarantees that you can choose any physician you want."
D. "HIPAA requires hospitals to provide charity care to uninsured clients."
Correct Answer: B
Rationale: HIPAA establishes national standards to protect individuals' medical records and other
personal health information, including privacy and security provisions. Option A describes EMTALA
(Emergency Medical Treatment and Labor Act). Option C is incorrect—HIPAA does not guarantee
physician choice. Option D is incorrect—HIPAA does not mandate charity care provisions.
Q10: A nurse is prioritizing care for four clients. Which client should the nurse see first?