NCLEX Safe, Management and Effective Care
Environment Exam With 100 Verified
Questions,Answers And Rationales
**1. A charge nurse is delegating tasks. Which task is appropriate to
delegate to unlicensed assistive personnel (UAP)?**
A. Performing a focused respiratory assessment on a client with new-
onset dyspnea
B. Assisting a stable post-op client with ambulation to the hallway
C. Educating a client with diabetes about foot care
D. Titrating oxygen flow rate based on oxygen saturation readings
**Correct Answer: B**
**Rationale:** Assisting a stable client with ambulation is within the
UAP scope. Assessment (A), education (C), and titrating oxygen (D)
require nursing judgment and cannot be delegated to a UAP.
---
,**2. Which action demonstrates appropriate use of the five rights of
delegation?**
A. Delegate wound assessment to UAP after the client is stable
B. Delegate medication administration to UAP with proper training
C. Delegate feeding of a stable client with dysphagia to UAP under
supervision
D. Delegate complex discharge teaching to LPN
**Correct Answer: C**
**Rationale:** Delegation must consider the right task,
circumstance, person, communication, and supervision. Feeding a
stable client with dysphagia may be delegated to UAP with proper
supervision and training.
---
**3. A PN is reinforcing teaching about hand hygiene. Which client
statement indicates correct understanding?**
A. "I should wash my hands for at least 10 seconds."
B. "I can use hand sanitizer if my hands are visibly dirty."
C. "I should rub my hands until the sanitizer is completely dry."
D. "Soap and water are less effective than alcohol-based rubs."
,**Correct Answer: C**
**Rationale:** Hand sanitizer must be rubbed until dry (about 20
seconds). Handwashing requires ≥20 seconds (A incorrect). Sanitizer
is not for visible soil (B incorrect). Soap/water is equally or more
effective in some situations (D incorrect).
---
**4. Which action by the novice nurse indicates a need for further
teaching regarding Standard Precautions?**
A. The nurse fails to wear gloves to remove a dressing
B. The nurse applies an oxygen saturation monitor to the ear lobe
C. The nurse elevates the head of the bed to check the blood
pressure
D. The nurse places the extremity in a dependent position to acquire
a peripheral blood sample
**Correct Answer: A**
**Rationale:** The nurse who fails to wear gloves to remove a
contaminated dressing needs further instruction regarding Standard
Precautions. Removing a dressing involves potential contact with
blood or body fluids, requiring gloves.
, ---
**5. A client's temperature is 102.2°F (39°C) orally. What is the first
action the PN should take?**
A. Apply a cooling blanket
B. Remove excess blankets
C. Administer acetaminophen per order
D. Notify the provider
**Correct Answer: B**
**Rationale:** The first step is to remove excess blankets to promote
heat loss. Antipyretics and cooling blankets may follow, but reducing
insulation is the immediate non-pharmacologic measure.
---
**6. A client falls while walking to the bathroom. What is the priority
action?**
A. Help the client back to bed
B. Assess the client for injury
C. Complete an incident report
Environment Exam With 100 Verified
Questions,Answers And Rationales
**1. A charge nurse is delegating tasks. Which task is appropriate to
delegate to unlicensed assistive personnel (UAP)?**
A. Performing a focused respiratory assessment on a client with new-
onset dyspnea
B. Assisting a stable post-op client with ambulation to the hallway
C. Educating a client with diabetes about foot care
D. Titrating oxygen flow rate based on oxygen saturation readings
**Correct Answer: B**
**Rationale:** Assisting a stable client with ambulation is within the
UAP scope. Assessment (A), education (C), and titrating oxygen (D)
require nursing judgment and cannot be delegated to a UAP.
---
,**2. Which action demonstrates appropriate use of the five rights of
delegation?**
A. Delegate wound assessment to UAP after the client is stable
B. Delegate medication administration to UAP with proper training
C. Delegate feeding of a stable client with dysphagia to UAP under
supervision
D. Delegate complex discharge teaching to LPN
**Correct Answer: C**
**Rationale:** Delegation must consider the right task,
circumstance, person, communication, and supervision. Feeding a
stable client with dysphagia may be delegated to UAP with proper
supervision and training.
---
**3. A PN is reinforcing teaching about hand hygiene. Which client
statement indicates correct understanding?**
A. "I should wash my hands for at least 10 seconds."
B. "I can use hand sanitizer if my hands are visibly dirty."
C. "I should rub my hands until the sanitizer is completely dry."
D. "Soap and water are less effective than alcohol-based rubs."
,**Correct Answer: C**
**Rationale:** Hand sanitizer must be rubbed until dry (about 20
seconds). Handwashing requires ≥20 seconds (A incorrect). Sanitizer
is not for visible soil (B incorrect). Soap/water is equally or more
effective in some situations (D incorrect).
---
**4. Which action by the novice nurse indicates a need for further
teaching regarding Standard Precautions?**
A. The nurse fails to wear gloves to remove a dressing
B. The nurse applies an oxygen saturation monitor to the ear lobe
C. The nurse elevates the head of the bed to check the blood
pressure
D. The nurse places the extremity in a dependent position to acquire
a peripheral blood sample
**Correct Answer: A**
**Rationale:** The nurse who fails to wear gloves to remove a
contaminated dressing needs further instruction regarding Standard
Precautions. Removing a dressing involves potential contact with
blood or body fluids, requiring gloves.
, ---
**5. A client's temperature is 102.2°F (39°C) orally. What is the first
action the PN should take?**
A. Apply a cooling blanket
B. Remove excess blankets
C. Administer acetaminophen per order
D. Notify the provider
**Correct Answer: B**
**Rationale:** The first step is to remove excess blankets to promote
heat loss. Antipyretics and cooling blankets may follow, but reducing
insulation is the immediate non-pharmacologic measure.
---
**6. A client falls while walking to the bathroom. What is the priority
action?**
A. Help the client back to bed
B. Assess the client for injury
C. Complete an incident report
