CSLB General Building (B) — All Questions

A charge nurse is assigning tasks at the start of a shift. Which task is appropriate to delegate to unlicensed assistive personnel (UAP)?

• a.Taking vital signs on a stable postoperative client✓
• b.Performing the initial assessment of a newly admitted client
• c.Adjusting the flow rate of a continuous IV infusion
• d.Teaching a client how to use an incentive spirometer

UAP may perform routine, standardized tasks such as vital signs on stable clients. Assessment, IV titration, and client teaching require the judgment of a licensed nurse and cannot be delegated.

A nurse must see four clients. Which client should the nurse assess FIRST?

• a.A client scheduled for discharge who needs teaching
• b.A client reporting new-onset shortness of breath and chest tightness✓
• c.A client requesting pain medication for a headache
• d.A client asking for help ambulating to the bathroom

Airway and breathing problems take priority. New shortness of breath with chest tightness may signal a life-threatening event and must be evaluated before less urgent needs.

Which nursing task is appropriate to delegate to a licensed practical/vocational nurse (LPN/LVN)?

• a.Developing the initial plan of care
• b.Providing discharge teaching about a new diagnosis
• c.Administering an oral medication to a stable client✓
• d.Performing triage in the emergency department

LPNs/LVNs may administer many routine medications and reinforce teaching for stable clients. Care planning, initial teaching, and triage require the broader scope of the registered nurse.

The nurse is caring for four clients. Applying the ABC framework, which finding requires the most immediate action?

• a.Blood pressure of 148/88 mm Hg
• b.Temperature of 100.8 F (38.2 C)
• c.Reports of mild incisional pain
• d.Oxygen saturation of 86% on room air✓

An oxygen saturation of 86% reflects a breathing and oxygenation emergency and takes priority over an elevated blood pressure, a low-grade fever, or mild pain.

A nurse delegates client hygiene to a UAP. Which statement reflects the nurse's continued accountability?

• a.The nurse remains accountable for the overall client outcome and must follow up✓
• b.The UAP is fully responsible for the outcome once the task is assigned
• c.Accountability transfers to the provider who wrote the orders
• d.No follow-up is required if the UAP is experienced

Delegation transfers the task, not the accountability. The RN retains responsibility for the outcome and must supervise and evaluate the delegated care.

Which situation is the highest priority for the nurse to report to the oncoming shift during handoff?

• a.A client whose dressing was changed two hours ago
• b.A client with a newly inserted chest tube and unstable vital signs✓
• c.A client who ate 100% of the evening meal
• d.A client who ambulated in the hallway without difficulty

Handoff should emphasize the least stable, highest-risk client. A new chest tube with unstable vital signs requires close monitoring and clear communication to ensure continuity of care.

A nurse observes a coworker preparing to administer a medication without checking the client's identification band. What is the nurse's best initial action?

• a.Report the coworker to the state board of nursing
• b.Document the observation in the client's chart
• c.Remind the coworker to verify two client identifiers before administration✓
• d.Say nothing because no harm has occurred yet

The immediate priority is client safety. Reminding the coworker to verify two identifiers prevents a potential error. Formal reporting is reserved for repeated or unresolved unsafe practice.

The nurse is planning care for a group of clients. Which client is most appropriate to assign to a newly graduated RN?

• a.A client requiring titration of a vasoactive drip
• b.A client actively receiving blood who is having a reaction
• c.A client being emergently transferred to the ICU
• d.A stable client needing routine postoperative care on day two✓

A new graduate should be assigned stable, predictable clients. Complex, rapidly changing situations such as drip titration, transfusion reactions, and ICU transfers require experienced staff.

A client refuses a prescribed treatment. Which action by the nurse best respects client autonomy?

• a.Documenting the refusal and notifying the provider✓
• b.Administering the treatment because the provider ordered it
• c.Telling the client they will be discharged if they refuse
• d.Waiting until a family member can convince the client

Competent clients have the right to refuse treatment. The nurse documents the informed refusal and notifies the provider, respecting autonomy while ensuring continuity of care.

Which of the following is the nurse's primary responsibility when a client signs a surgical consent form?

• a.Explaining the surgical risks and alternatives to the client
• b.Verifying that the client's consent is voluntary and witnessing the signature✓
• c.Deciding whether the client should proceed with surgery
• d.Guaranteeing that the surgery will be successful

The provider is responsible for explaining risks, benefits, and alternatives. The nurse verifies that consent is voluntary and informed and witnesses the signature.

A nurse is prioritizing care using Maslow's hierarchy of needs. Which client need should be met first?

• a.A client's need for reassurance about surgery
• b.A client's request to see the hospital chaplain
• c.A client's difficulty maintaining a patent airway✓
• d.A client's concern about the cost of care

Physiological needs such as a patent airway are the base of Maslow's hierarchy and take priority over safety, love and belonging, esteem, and self-actualization needs.

The nurse receives report on four clients. Which client should the nurse plan to reassess first after receiving report?

• a.A client with chronic stable heart failure awaiting discharge
• b.A client with a healing surgical wound scheduled for a dressing change
• c.A client requesting a snack before bedtime
• d.A client who received IV morphine 15 minutes ago and is now very drowsy✓

A client who is increasingly drowsy after IV opioids may be developing respiratory depression and must be reassessed first to prevent harm.

Which task can the RN appropriately delegate to a UAP for a client on strict intake and output monitoring?

• a.Emptying the urinary drainage bag and recording the amount✓
• b.Interpreting the significance of a low urine output
• c.Deciding whether to notify the provider about the output
• d.Adjusting the client's fluid restriction

Measuring and recording output is a routine task suitable for UAP. Interpreting values, clinical decision-making, and modifying the plan of care remain RN responsibilities.

A nurse is coordinating a client's discharge. Which action best demonstrates effective case management?

• a.Delaying discharge until every family question is answered in person
• b.Arranging home health services and follow-up appointments before discharge✓
• c.Providing only verbal instructions to save time
• d.Leaving medication reconciliation to the community pharmacy

Effective case management coordinates resources across the continuum of care. Arranging home health and follow-up appointments promotes continuity and reduces readmission risk.

The nurse identifies a near-miss medication error that did not reach the client. What is the appropriate action?

• a.Ignore it because the client was not harmed
• b.Record it in the client's medical record as an error
• c.Complete an incident and occurrence report to support system improvement✓
• d.Report it directly to the state licensing board

Near-miss and error events are documented on an incident report for quality improvement. The report is not filed in the medical record, and licensing boards address serious professional issues only.

A nurse is supervising a UAP. Which observed action requires the nurse to intervene?

• a.The UAP raises the side rails after repositioning a client
• b.The UAP offers a bedpan to a client on bed rest
• c.The UAP reports a blood pressure to the nurse
• d.The UAP applies a vest restraint without a current provider order✓

Restraints require a current provider order and specific criteria. Applying a restraint without an order is unsafe and unlawful, so the nurse must intervene immediately.

Which principle should guide the nurse when assigning client care during a staffing shortage?

• a.Match client acuity and complexity to staff competency✓
• b.Assign the most clients to the least experienced staff
• c.Give all unstable clients to a single nurse to concentrate care
• d.Distribute clients randomly to save time

Safe assignment matches client acuity to the skill and scope of the staff member. Overloading unstable clients on one nurse or assigning complex clients to novices threatens safety.

A nurse witnesses a colleague documenting care that was not actually provided. Which ethical principle is most directly violated?

• a.Autonomy
• b.Veracity✓
• c.Beneficence
• d.Justice

Veracity is the duty to tell the truth. Falsifying documentation violates veracity and is both an ethical breach and a legal risk.