NCLEX-RN Nursing — 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.Adjusting the flow rate of a continuous IV infusion
• b.Taking vital signs on a stable postoperative client✓
• c.Performing the initial assessment of a newly admitted client
• 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 requesting oral pain medication for a mild headache
• b.A client asking for help ambulating to the bathroom after lunch
• c.A client scheduled for discharge who still needs some teaching
• d.A client reporting new-onset shortness of breath and chest tightness✓

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

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 while seated
• b.Oxygen saturation of 86% on room air✓
• c.Reports of mild pain at the incision site
• d.Tympanic temperature of 100.8 F (38.2 C)

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

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

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.Say nothing for now, because no harm has come to the client yet
• b.Document the observation in the client's chart after the medication is given
• c.Report the coworker to the state board of nursing before speaking to anyone
• d.Remind the coworker to verify two client identifiers before administration✓

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

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.Administering the treatment because the provider ordered it
• b.Telling the client they will be discharged if they refuse
• c.Documenting the refusal and notifying the provider✓
• 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.Guaranteeing that the surgery will be successful before the signature
• b.Deciding whether the client should proceed with the planned surgery
• c.Verifying that the client's consent is voluntary and witnessing the signature✓
• d.Explaining the surgical risks, benefits, and alternatives to the client

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

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 who is awaiting discharge
• b.A client who received IV morphine 15 minutes ago and is now very drowsy✓
• c.A client requesting a bedtime snack from the unit kitchen tonight
• d.A client with a healing surgical wound scheduled for a dressing change

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.Interpreting the significance of a low hourly urine output
• b.Emptying the urinary drainage bag and recording the amount✓
• c.Deciding whether to notify the provider about the low output
• d.Adjusting the client's prescribed 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.Arranging home health services and follow-up appointments before discharge✓
• b.Delaying discharge until every family question is answered in person
• c.Providing only verbal discharge instructions to save the client time
• d.Leaving the medication reconciliation to the community pharmacy later

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.Complete an incident and occurrence report to support system improvement✓
• b.Report it directly to the state licensing board so that they can investigate
• c.Ignore it entirely, since no harm reached the client and nothing needs filing
• d.Record the near miss in the client's medical record as a medication error

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

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

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

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

A nurse is admitting a 78-year-old client who lives alone and was hospitalized after a hip fracture. At what point should the nurse begin discharge planning for this client?

• a.At admission, by identifying the client's likely need for post-hospital services✓
• b.On the day of discharge, after the provider writes the order and names a destination
• c.Once the client can walk the hallway with the walker without assistance
• d.When the client's insurance company approves a post-acute rehabilitation placement

The federal discharge planning requirement directs hospitals to identify, early in the stay, clients likely to suffer adverse consequences without adequate planning, so needs such as home health or extended care are worked out from admission onward. Waiting for the discharge order compresses planning into a few hours and is a common cause of failed transitions and readmission.

A nurse is transferring a client from the intensive care unit to a medical unit. The client has a patient-controlled analgesia pump and an indwelling urinary catheter. Which action by the transferring nurse best supports a safe transfer?

• a.Ask the client's daughter to explain the pump to the new nurse on arrival
• b.Give a face-to-face report to the receiving nurse and allow time for questions✓
• c.Send the printed transfer summary and let the receiving nurse read it later
• d.Chart a transfer note after the client has been moved to the new room

The Joint Commission's hand-off alert directs senders to communicate critical content both verbally, preferably face to face, and in writing, with ample opportunity for the receiver to ask questions, and warns against hand-offs made solely through paper or electronic communication. A written summary alone is the tempting choice because the information is technically transmitted, but nothing confirms the receiver got what was needed to manage the pump and catheter.

A nurse is using the ISBAR format to call a provider about a client whose urine output has fallen. Which statement belongs in the recommendation portion of the report?

• a.I am Dana Ruiz, the nurse caring for the client in room 412 tonight.
• b.The client has put out only 60 mL of urine over the past four hours.
• c.The client had an open cholecystectomy two days ago and has no allergies.
• d.I would like you to assess the client now and consider a fluid order.✓

In ISBAR the recommendation names what the nurse wants the provider to do, which is what converts a report into a request for action. The urine-output figure is the most tempting wrong choice because it is the reason for the call, but a measured finding is the situation being described, not the recommendation; the surgical history is background and the nurse's name is identification.

A unit uses the I-PASS mnemonic to structure shift hand-off. Which action carries out the final element, synthesis by the receiver?

• a.The departing nurse repeats the report a second time before leaving
• b.The oncoming nurse restates the plan and to-do list back to the sender✓
• c.The departing nurse files the completed hand-off form in the client record
• d.The oncoming nurse signs the printed hand-off sheet before rounds begin

I-PASS stands for illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver, so the closing step belongs to the person receiving the client: summarizing back what was heard while the sender is still there to correct it. Signing the hand-off sheet records that a report happened but does not test whether the information arrived intact.

A client with two surgical drains and a pain pump is being transferred to a rehabilitation unit. The client's spouse says he will explain the drains and the pump to the new staff when they arrive. Which action should the nurse take?

• a.Report the drains and pump to the receiving nurse with the spouse present✓
• b.Tell the spouse that device information is not shared with family members
• c.Thank the spouse and let him relay the device details to the receiving staff
• d.Write the device details on a note for the spouse to hand to the new staff

The Joint Commission encourages sharing hand-off information with the client and family present, yet states plainly that clinicians should not rely on the client or family to communicate vital information about their care to the providers receiving the hand-off. Sending the details on a note carried by the spouse has the same flaw: the transfer of clinical responsibility still has to happen nurse to nurse.

At the end of the shift an RN transfers responsibility for a client's care to the oncoming RN. Under the NCSBN and ANA national guidelines, this transfer is best described as which of the following?

• a.Delegation of a nursing responsibility to a delegatee
• b.A hand-off between licensed health care providers✓
• c.Supervision of one licensed nurse by another
• d.An assignment of routine care by a nurse leader

The national delegation guidelines state that they do not apply to the transfer of responsibility for care of a patient between licensed health care providers, such as RN to RN, which is considered a hand-off. Delegation is the narrower act of transferring one specific nursing activity to a delegatee who would not routinely perform it, and it never moves the whole client.

An RN is caring for a stable client with type 2 diabetes. Which responsibility may the RN delegate to an experienced assistive personnel (AP) with documented competency?

• a.Assessing a new area of redness the client reports on the heel
• b.Deciding whether the ordered sliding-scale insulin dose should be given
• c.Teaching the client how and why to rotate the insulin injection sites
• d.Obtaining a capillary blood glucose reading and reporting the value✓

A point-of-care glucose measurement performed to protocol and reported back to the nurse is a task an AP can be trained and validated to do. Choosing the insulin decision is tempting because the AP produced the number, but the national guidelines state that the licensed nurse cannot delegate nursing judgment or any activity involving critical decision making; teaching and assessment are retained on the same grounds.

An RN delegated a morning bath to an AP for a client who was stable at the start of the shift. The AP returns and reports that the client became dizzy and confused while sitting up. Which action should the RN take first?

• a.Have the AP recheck the client's vital signs again in one hour
• b.Reassess the client and decide whether the delegation is still appropriate✓
• c.Reassign the bath to a different AP who has more years of experience
• d.Direct the AP to finish the bath while staying with the client the whole time

The right circumstance requires that the client's condition be stable, and the guidelines state that when the condition changes the delegatee must communicate it and the licensed nurse must reassess the situation and the appropriateness of the delegation. Sending the AP back to finish is tempting because the AP is already at the bedside, but new dizziness and confusion are findings only the RN can evaluate.

A charge nurse asks an AP to apply and monitor sequential compression devices. The AP says she has not used the devices before and does not feel able to do it safely. Which action is correct?

• a.The AP proceeds after another AP describes how the devices are used
• b.The AP proceeds, because the nurse keeps accountability for the client
• c.The AP declines, and the nurse applies the devices or arranges training✓
• d.The AP documents the concern in the record and applies the devices

The guidelines state that a delegatee who does not believe he or she has the competency to complete a delegated responsibility should not accept it, and that when delegation is not appropriate the delegating nurse should perform the activity herself. The accountability answer is tempting and half true: the nurse does retain accountability, which is a reason for her to act, not a reason for an untrained delegatee to proceed.

An RN is distributing work on a unit staffed with RNs, LPN/VNs, and AP. Which responsibility is appropriate to assign to the LPN/VN?

• a.Writing the outcome goals in a newly admitted client's care plan
• b.Performing the admission assessment on a client arriving from surgery
• c.Reinforcing low-sodium diet instructions the RN taught yesterday✓
• d.Evaluating whether teaching about a new diagnosis was effective

Reinforcing instruction the RN has already delivered sits inside the LPN/VN role, while the initial assessment, development of the plan of care, and evaluation of teaching are clinical-judgment steps the RN retains. LPN/VN scope varies by state, so the reliable way to answer these items is to look for the retained RN core rather than to reason from a particular state's task list.

A state nurse practice act permits AP to remove peripheral IV catheters, but the hospital's written policy states that only licensed nurses may remove them. Which statement about the nurse's obligation is correct?

• a.The nurse follows the hospital policy, which may be more restrictive✓
• b.The nurse may delegate the removal once the AP has been checked off by an educator
• c.The nurse follows the practice act, which overrides the local policy
• d.The nurse may delegate the removal with the charge nurse's approval

The national guidelines require employer delegation policies to be consistent with the practice act and note that institution or employer policies can be more restrictive, but not less restrictive, than the act. A permissive practice act sets an outer boundary rather than a permission slip, and no individual nurse or charge nurse can waive a facility policy that withholds the task.

A nurse is giving discharge medication instructions to a client with limited English proficiency. The client's 15-year-old grandson offers to interpret. Which action should the nurse take?

• a.Ask a bilingual assistive personnel on the unit to interpret the instructions
• b.Give written instructions in the client's language and omit the verbal teaching
• c.Obtain a qualified interpreter through the hospital at no cost to the client✓
• d.Allow the grandson to interpret, since the client trusts him to be accurate

Federal rules require covered health programs to provide language assistance free of charge, accurately and in a timely way, and prohibit relying on a minor child to interpret except briefly in an emergency while a qualified interpreter is found. Asking bilingual staff is the closest wrong answer, because a staff member who speaks the language is not automatically qualified as an interpreter.

A client recovering from a stroke tells the nurse she wants to return to her own home with help, while her adult children have already toured a skilled nursing facility. Which action by the nurse best advocates for the client?

• a.Explain to the client that her children have picked the safer care setting for her
• b.Ask the children to spend more time persuading the client to agree to the plan
• c.Document the client's wish in the record and continue with the facility placement
• d.Bring the client's stated goal to the discharge planning team for evaluation✓

The discharge planning regulation requires a process that focuses on the client's own goals and treatment preferences and that treats the client and caregivers as active partners, so advocacy means getting the stated goal formally evaluated, including whether home health could meet the need. Documenting the wish and proceeding anyway is the near-miss answer: it creates a record without giving the client any part in her own plan.

Four clients on a surgical unit press their call lights at the same time. Which client should the nurse go to first?

• a.A client 2 days after abdominal surgery who is asking for an antiemetic
• b.A client 1 day after knee replacement rating incisional pain 6 of 10
• c.A client 3 days after bowel resection who has not yet passed any flatus
• d.A client 4 hours after thyroidectomy with a high-pitched inspiratory sound✓

A high-pitched inspiratory sound is stridor, described by MedlinePlus as caused by a blockage in the throat or larynx and treated as an emergency; after thyroidectomy it can mean the airway is narrowing from swelling or a hematoma, so it outranks pain, nausea, and delayed flatus. The other three findings need attention during the shift but none of them is an airway problem.

A nurse begins the shift with four clients. Which client is appropriate for the nurse to see last?

• a.A client reporting sudden pain and tightness in one calf while resting
• b.A client whose oxygen saturation fell from 96% to 89% on 2 L of oxygen
• c.A client with new confusion who was fully oriented at the previous shift
• d.A client waiting on routine morning labs before a planned discharge✓

Waiting on routine results before a planned discharge is the only situation with no change in the client's condition, while altered mental status and an oxygen saturation below 90% are both standard rapid-response calling criteria and new unilateral calf pain may signal a clot. Deciding who can wait uses the same acuity judgment as deciding who is first, applied from the other end of the list.

Two days after an ischemic stroke, a client coughs after sips of water and has a wet, gurgly voice at the end of the meal. Which action should the nurse take?

• a.Thicken the client's liquids and finish the rest of the meal at the bedside
• b.Have the assistive personnel feed the client slowly while sitting upright
• c.Record the finding and watch the client closely again at the next meal
• d.Stop oral intake and request an order for a swallowing evaluation✓

Coughing during or after drinking and a wet or gurgly voice are signs ASHA lists as warranting a swallowing assessment by a speech-language pathologist, and both that referral and any diet change need a provider order. Thickening the liquids is the most tempting wrong action because it feels protective, but it is a treatment decision outside the nurse's independent scope and ASHA notes thickened fluids may not eliminate aspiration risk.

A client with end-stage kidney disease is ready for discharge but has no stable housing and no way to get to outpatient dialysis three times a week. Which referral should the nurse initiate?

• a.Physical therapist, to build the endurance needed for the trip to dialysis
• b.Dietitian, to build a renal meal plan the client can follow at a shelter
• c.Social worker, to connect the client with housing and transport resources✓
• d.Occupational therapist, to adapt daily routines around the dialysis schedule

Social workers research, refer to, and advocate for community resources such as housing and health care, and health care social workers specifically help people move from the hospital back into their communities. The other three consults address real needs, but none of them removes the housing and transportation barrier that will otherwise stop the dialysis from happening at all.

A home health nurse determines that a client who is unsteady on stairs would benefit from gait training and a bedside commode. Which action should the nurse take next?

• a.Tell the family to buy a commode and to supervise the stairs at home
• b.Ask the home health aide to walk the client on the stairs each visit
• c.Add gait training to the plan of care and begin the exercises today
• d.Contact the provider to obtain orders for therapy and the equipment✓

Identifying the need is nursing judgment, but home health services are delivered under a plan of care established and signed by a physician or allowed practitioner that must specify the types of services, supplies, and equipment required, so the orders are what turn the assessment into delivered care. Starting gait training independently substitutes the nurse for the discipline whose scope covers it.

A care plan goal states that a client will ambulate 50 feet with a walker by postoperative day 3. On day 3 the client has walked only to the bathroom door. Which action reflects the evaluation step of the nursing process?

• a.Delete the mobility goal and document that the client declined it
• b.Record the goal as met, because the client did get out of bed today
• c.Identify what limited progress and revise the goal and interventions✓
• d.Keep the plan unchanged and re-evaluate the same goal on postoperative day 5

Evaluation means reassessing whether the desired outcome was achieved and then adapting the plan of care on the new data, so an unmet goal triggers revision of the goal and the interventions behind it. Recording the goal as met because the client moved at all is the tempting error, since it changes the documentation instead of the care.

At 0700 a nurse has these tasks: a client due in the operating room at 0730 who has not voided, an 0800 insulin dose, a 0900 dressing change, and a routine bed bath. Which task should the nurse do first?

• a.Complete the bed bath so that the rest of the morning stays clear
• b.Draw up and give the scheduled 0800 dose of the client's insulin
• c.Change the surgical dressing that is scheduled for 0900 this morning
• d.Assist the pre-operative client to void before transport at 0730✓

Organizing a workload means working outward from the deadlines that other departments own: the transport time is set by the operating room and cannot be moved, while the insulin and the dressing change have later windows and the bath has none. Doing the bath first to clear the morning is the classic error, because it spends the only uncommitted block on the only task with no deadline.

A nurse has six clients and two new admissions arriving within the hour, and one AP is available. Which approach best organizes the workload?

• a.Delegate the admission assessments so the nurse can finish the medication pass on time
• b.Delegate the tasks and check the results at the end of the shift report
• c.Delegate vital signs and hygiene for the stable clients, with reporting limits✓
• d.Keep every task, because explaining the work takes longer than doing it alone

Handing routine care for stable clients to the AP with specific values to report back frees the RN for the assessments and admissions only she can do, and it satisfies the right directions and communication element of delegation. Delegating the admission assessments fails the right task, and delegating without following up until report fails the right supervision and evaluation.

Over 20 minutes a client's respiratory rate rises from 18 to 30 and the client becomes confused. The nurse has paged the provider twice with no response. Which action should the nurse take?

• a.Raise the oxygen flow rate and reassess the client in 30 minutes
• b.Page the provider a third time and recheck the client in 15 minutes
• c.Ask the charge nurse to move the client closer to the nurses station
• d.Activate the rapid response team for the client's change in condition✓

Rapid response systems exist to bring critical care skill to a deteriorating client before an arrest, and their calling criteria include altered mental status, an abnormal respiratory rate, and a staff member's significant concern about the client, with no provider authorization required to call. Paging again while the client worsens is exactly the failure-to-rescue pattern these teams were built to interrupt.

A medical-surgical nurse is floated to an oncology unit and assigned to give an intravenous chemotherapy infusion she has not been trained to administer. Which action should the nurse take?

• a.Decline the entire float assignment and return to her home unit
• b.Give the infusion while an oncology nurse talks her through each step
• c.Tell the charge nurse she is not trained and ask for a different client✓
• d.Read the unit protocol and give the infusion at the scheduled time

A delegatee, including a licensed nurse, must accept only responsibilities she is trained and competent to carry out and must tell nursing leadership when she has not had adequate training, which lets the charge nurse move that client and give her work within her competence. Walking off the float assignment is the tempting overcorrection: recognizing a limitation means renegotiating the task, not leaving a short unit shorter.

A client with left-sided weakness after a stroke walks safely with a cane but cannot dress himself or manage utensils. Which team member should the nurse consult?

• a.Occupational therapist, for retraining in dressing and eating tasks✓
• b.Speech-language pathologist, for retraining in swallowing and speech
• c.Respiratory therapist, for retraining in breathing and airway clearance
• d.Physical therapist, for retraining in walking and stair-climbing tasks

Occupational therapists help clients relearn daily living tasks, including teaching a person who has had a stroke how to get dressed, and they recommend eating aids and other adaptive equipment. Physical therapy is the tempting pick after a stroke, but this client's gait is already safe with a cane and the deficit is in self-care activities.

A client with COPD has thick retained secretions and a weak cough, and the provider has ordered chest physiotherapy and a change in oxygen delivery. Which team member should the nurse collaborate with to carry out these orders?

• a.Registered dietitian, who plans the intake needed to support breathing
• b.Respiratory therapist, who gives chest physiotherapy and sets up oxygen✓
• c.Physical therapist, who gives endurance training and gait retraining
• d.Clinical social worker, who arranges home equipment and follow-up care

Respiratory therapists perform chest physiotherapy to move mucus out of the lungs and set up and monitor the equipment that delivers the correct amount of oxygen at the correct rate, which is precisely what these two orders require. The other consults are reasonable later in the stay, but none of them executes the ordered airway clearance.

A client scheduled for a laparoscopic cholecystectomy in 45 minutes tells the nurse, “I signed the paper, but I still don’t know what they plan to remove or what could go wrong.” The preoperative midazolam has not yet been given. Which action should the nurse take?

• a.Ask the client’s spouse to explain the procedure the surgeon described earlier
• b.Describe the procedure and its usual risks to the client and then proceed
• c.Give the midazolam as ordered and reinforce the teaching once the client is calm
• d.Notify the surgeon to discuss the procedure before sedation is given✓

The provider who will perform the procedure is responsible for explaining its nature, risks, benefits, and alternatives; the nurse verifies that the client understood and alerts the surgeon when that understanding is missing. Explaining the procedure in the surgeon’s place does not create valid informed consent.

A nurse is asked to witness a surgical consent signature 10 minutes after intravenous midazolam was given to the client. Which action should the nurse take?

• a.Ask a second nurse to co-sign the consent form to confirm the client was alert
• b.Decline to witness and tell the surgeon that consent must be obtained first✓
• c.Witness the signature and note in the record that midazolam was given first
• d.Witness the signature after the client repeats the name of the planned procedure

Consent signed while a client is under a sedating drug is not valid, because the client can no longer demonstrate understanding of what is being agreed to; the discussion and signature belong before sedation. Documenting the sedation or adding a second signature does not restore the client’s capacity to consent.

An unresponsive adult is brought to the emergency department after a motor vehicle crash and needs immediate surgery for internal bleeding. No family member or surrogate decision maker can be located. Which statement should guide the nurse’s action?

• a.Emergency treatment may proceed under the emergency exception to informed consent✓
• b.Surgery must be delayed until a family member is located and gives permission
• c.A court order is required before any surgical procedure may be performed
• d.Two staff members may sign the consent form on behalf of the unresponsive client

Informed consent may be waived when an emergency leaves no time to obtain it, the client cannot communicate, and no surrogate is available, because a reasonable person would be presumed to want life-saving care. Delaying hemorrhage surgery to locate a family member who cannot be found would cause the harm consent rules exist to prevent.

A 17-year-old client who is married and living independently presents alone for treatment of a fractured wrist. The client’s parents live in another state. Which action should the nurse take regarding consent?

• a.Treat the injury under implied consent because the client arrived alone
• b.Have the client sign the consent, because a married minor is emancipated✓
• c.Telephone a parent in the other state for permission before treating
• d.Ask the client’s spouse to sign the consent form for the wrist treatment

A minor who is legally emancipated — for example through marriage, military service, or a court order — gives their own informed consent for care. Implied consent covers emergencies in which the client cannot communicate a decision, which does not apply to an alert client with a wrist fracture.

A nurse is teaching a client about advance directives. Which client statement indicates that the teaching was effective?

• a.“An advance directive is required before the hospital can admit me for care.”
• b.“A durable power of attorney for health care names who speaks for me.”✓
• c.“My advance directive takes effect the moment I sign it in front of a notary.”
• d.“A living will lets my daughter choose my treatments while I am still alert.”

A durable power of attorney for health care designates a health care proxy to speak for the client, while a living will records treatment preferences without naming a decision maker. Advance directives take effect only when the client can no longer make or communicate decisions, and a facility may not require one as a condition of care.

A client with a living will refusing mechanical ventilation is alert, oriented, and able to state their wishes. The client now tells the nurse, “If it would only be for a few days, I would want the breathing machine.” Which action should the nurse take?

• a.Tell the client the directive can be changed only by an attorney at a later date
• b.Document the client’s current wishes and notify the provider of the change✓
• c.Ask the client’s health care proxy to decide whether ventilation should be used
• d.Follow the living will, because a signed directive overrides later spoken wishes

An advance directive guides care only when the client can no longer make or communicate decisions, so an alert client with capacity speaks for themselves and may revise their wishes at any time. The proxy’s authority begins when capacity is lost, so turning to the proxy now would displace the client’s own voice.

A nurse is admitting an adult client to a hospital that participates in Medicare. Which action meets the facility’s federal obligation regarding advance directives?

• a.Provide directive information only to clients admitted for terminal conditions
• b.Ask whether the client has an advance directive and document the answer in the record✓
• c.Have the client’s family complete a directive if the client has not done so
• d.Require the client to complete an advance directive before care is provided

Federal rules require providers to give each adult written information about advance directives and to document in a prominent part of the record whether the individual has executed one. Care may not be conditioned on whether a directive exists, so requiring one before treatment would violate the rule.

A client with metastatic cancer has a do-not-resuscitate order written by the provider. The client develops a temperature of 102.6 F (39.2 C) and reports pain rated 8 of 10. Which action should the nurse take?

• a.Give the prescribed antipyretic and analgesic and continue routine monitoring✓
• b.Limit care to hygiene and repositioning until the family can be contacted
• c.Ask the provider to rescind the order before treating the fever and pain
• d.Withhold the analgesic because comfort measures conflict with the written order

A do-not-resuscitate order directs staff not to perform cardiopulmonary resuscitation; every other prescribed treatment, including antipyretics, analgesia, and monitoring, continues unchanged. Treating fever and pain does not conflict with the order, so there is nothing to rescind.

A nurse posts on a personal social media account: “Long shift with my 32-year-old motorcycle crash guy in room 12 — three surgeries and he is still smiling.” No name appears in the post. How should this post be evaluated?

• a.It is acceptable, because the account is set to be seen by friends
• b.It is acceptable, because no name or medical record number appears
• c.It breaches confidentiality only if the client’s family reads the post
• d.It breaches confidentiality, because the details identify the client✓

Describing a client by room number, age, and circumstance still allows identification, so the post is a breach of confidentiality even though no name is used. Privacy settings and later deletion give no protection, because posted content can be copied and remains retrievable.

An alert, oriented client is in bed when an adult son arrives and asks the nurse for the results of the morning laboratory tests. Which action should the nurse take?

• a.Tell the son that laboratory results are released only by the provider
• b.Ask the client, in the son’s presence, whether the results may be shared✓
• c.Direct the son to submit a written request to the medical records department
• d.Give the results, because a son is a member of the immediate family

When the client is present and has capacity, information may be shared with a family member if the client agrees or is given a chance to object, so the client controls the disclosure. Being a close relative does not by itself authorize release of results.

A charge nurse is reviewing electronic health record access logs for the unit. Which finding requires the charge nurse to intervene?

• a.A nurse opened the chart of a neighbor on another unit✓
• b.A nurse reviewed the chart of a client assigned to her tonight
• c.A nurse read the surgical history of a client she is admitting
• d.A nurse opened a chart to check an order for a client she covers

Client information may be accessed only by team members actively involved in that client’s care, so opening a neighbor’s chart out of concern or curiosity is a privacy violation even if nothing is repeated to anyone. Reviewing charts of assigned or covered clients is a permitted use for treatment.

A charge nurse asks an RN who has not completed the facility’s chemotherapy certification to hang a vesicant chemotherapy infusion because the unit is short-staffed. Which response by the RN is appropriate?

• a.“I will hang it and document that I was directed to give it while short-staffed.”
• b.“I will hang it because the order is written and the pharmacy prepared it.”
• c.“I have not completed the chemotherapy competency, so I cannot hang that infusion.”✓
• d.“I will hang it if you stay in the room and observe me for the first hour.”

A nurse is personally accountable for practicing within their scope and demonstrated competence, and a staffing shortage, a valid order, or a note about who gave the direction does not transfer that accountability. Being watched by another nurse is not a substitute for the required competency.

A hospital policy permits RNs to perform a procedure that the state’s nurse practice act does not include within the RN scope of practice. Which understanding should guide the nurse?

• a.The hospital policy governs, because the employer accepts the legal liability
• b.The nurse practice act sets the limit, so the nurse should not perform it✓
• c.The procedure is allowed once the nurse is checked off by a unit educator
• d.The procedure is allowed if a provider writes an order authorizing it

The state’s nurse practice act and board of nursing define what a licensed nurse may legally do; employer policy, a provider’s order, and an in-house competency check cannot widen that legal scope. A nurse who practices beyond the act risks licensure discipline no matter who directed the act.

A nurse tells a client, “I will be back at 2 p.m. to walk with you in the hallway.” Despite a heavy assignment, the nurse returns at 2 p.m. as promised. Which ethical principle does this action demonstrate?

• a.Justice, which is the fair distribution of nursing care
• b.Fidelity, which is keeping promises made to the client✓
• c.Nonmaleficence, which is the duty to avoid causing harm
• d.Veracity, which is telling the client the truth

Fidelity is faithfulness to the commitments and promises a nurse makes to a client, which is exactly what returning at the promised time demonstrates. Veracity concerns truthfulness in what the nurse tells the client rather than following through on an agreement.

A nurse believes a dying client’s pain is undertreated but is directed by unit leadership to follow the current order and not contact the provider. The nurse continues to feel troubled about the client’s suffering. Which term best describes what the nurse is experiencing?

• a.Moral courage, acting on ethical values despite the personal risk involved
• b.Moral distress, knowing the right action but being blocked from taking it✓
• c.Ethical uncertainty, being unsure which ethical principles apply in the case
• d.Ethical dilemma, choosing between two options of equal ethical weight

Moral distress arises when the nurse has identified the ethically correct action but is blocked from carrying it out by organizational or other constraints. An ethical dilemma is different: there the nurse must choose between competing options rather than being prevented from acting on one already judged right.

A nurse caring for a 4-year-old notes bruises in several stages of healing across the child’s back, and the parent’s explanation does not match the pattern of injury. Which action should the nurse take?

• a.Ask the parent for written permission to report the injuries to the state
• b.Gather proof of abuse before making a report to an outside agency
• c.Report the suspicion to child protective services as a mandated reporter✓
• d.Wait for the provider to decide whether the injuries should be reported

Nurses are mandated reporters and must report a reasonable suspicion of abuse; proof, parental permission, and a provider’s agreement are not prerequisites, and federal privacy rules permit the disclosure to the authority receiving such reports. Waiting to build a case leaves the child in the setting where the injuries occurred.

A client is newly diagnosed with active pulmonary tuberculosis and tells the nurse, “I do not want anyone outside this hospital to know about this.” Which action should the nurse take?

• a.Agree to keep the diagnosis inside the hospital as the client requests
• b.Obtain the client’s written authorization before the case is reported
• c.Explain that the case is reported to the public health department as the law requires✓
• d.Report the case directly to the federal agency that tracks the disease

Tuberculosis is a reportable condition, and privacy rules permit disclosure of protected health information to a public health authority without the client’s authorization. Case reports go to state or local public health officials, who then notify federal surveillance, so the nurse does not report federally.

During a resuscitation, a provider gives the nurse a verbal medication order. Which action by the nurse meets the standard for receiving a verbal order?

• a.Ask a second nurse to listen to the order and confirm what was said
• b.Enter the order into the record afterward and ask the provider to sign it
• c.Repeat the order aloud from memory and then carry it out immediately
• d.Write the order down and read it back to the provider for confirmation✓

The nurse receiving a verbal order writes it down and reads back what was written, which verifies both what was heard and what was transcribed; the prescriber then dates, times, and authenticates the order. Repeating from memory confirms only hearing, leaving a transcription error undetected.

A nurse reviews a newly written order that reads “digoxin .125 mg PO daily.” Which action should the nurse take?

• a.Have the prescriber rewrite the order with a leading zero✓
• b.Transcribe the order as 0.125 mg and give the dose without a call
• c.Ask another nurse to confirm the intended dose before giving it
• d.Give the dose as written, since the intent of the order is clear

A dose written without a leading zero reads as a whole number if the decimal point is missed, so “.125 mg” can be given as 125 mg; only the prescriber may correct their own order. A nurse rewriting the dose or getting a colleague’s opinion leaves the ambiguous original order in place.

A client is found on the floor beside the bed and is assessed as uninjured. After completing the facility’s occurrence report, what should the nurse document in the client’s medical record?

• a.A statement that an occurrence report was completed for this fall
• b.The nurse’s conclusion that the bed alarm had not been switched on
• c.The objective findings of the assessment and how the client was found✓
• d.A copy of the occurrence report filed behind the nursing progress notes

The chart carries the objective facts — how the client was found, the assessment, and what was done — while the occurrence report is a separate quality and risk-management document that is not included in the medical record and is not referenced in it. Charting a cause records an opinion rather than an observation.

A hospital convenes a root cause analysis after a client received a fatal dose of the wrong medication. Which statement describes the purpose of this process?

• a.To decide whether the event must be disclosed to the client’s family
• b.To find the system factors that allowed the error and change them✓
• c.To calculate the financial exposure the hospital faces from the event
• d.To identify the staff member at fault and apply corrective discipline

Root cause analysis repeatedly asks why an error reached the client in order to expose the process and system vulnerabilities behind it, then produces an action plan to correct them. It deliberately looks past the individuals involved, because disciplining one nurse leaves the same failure available to the next one.

A nurse is handwriting an entry on a paper medication administration record after giving a scheduled dose of insulin. Which entry uses approved terminology and abbreviations for the medical record?

• a.Regular insulin 6 units subcutaneously at 0730✓
• b.Regular insulin 6.0 units subcutaneously at 0730
• c.Regular insulin 6 U subcutaneously at 0730
• d.Regular insulin 6 IU subcutaneously at 0730

The Joint Commission's official 'Do Not Use' list governs every handwritten medication entry. Write 'unit' in full, because a handwritten 'U' is read as a zero, as a four, or as 'cc'. Write 'International Unit' in full, because 'IU' is read as 'IV' or as the number 10. And do not write a trailing zero after a decimal point, because 6.0 units is read as 60 units — a tenfold insulin overdose. Spelling out 'units' with no trailing zero is the entry that satisfies all three rules.

A client whose record lists the name “Robert” tells the nurse, “I go by Robin, and I use she and her.” Which action by the nurse is appropriate?

• a.Use the legal name on the record when other staff are present
• b.Ask the provider whether the client’s stated name may be used
• c.Use Robin and she and her, and record this in the client’s chart✓
• d.Use Robin with the client but Robert in the change of shift report

Nursing practice requires compassion and respect for the dignity and unique attributes of every person, so the nurse uses the name and pronouns the client states and passes them to the team through the record. Switching back to the legal name in front of staff tells the client that respect depends on who is listening.

Two nurses on a unit have argued repeatedly about who restocks the medication room, and the dispute is now disrupting handoff. Which approach by the nurse manager is most likely to resolve the conflict durably?

• a.Assign the restocking task to one nurse and end the discussion there
• b.Wait to see whether the two nurses settle the matter between themselves
• c.Ask each nurse to give up part of the task so both share the burden
• d.Bring both nurses together to build a plan that meets both their needs✓

Collaboration — surfacing what each party actually needs and building a shared solution — takes the most effort but produces the most durable resolution. Imposing a decision, splitting the difference, and waiting all leave the underlying interests unaddressed, so the conflict resurfaces.

At discharge a client tells the nurse, “That inhaler costs more than my share of the rent, so I will use it only when I feel really bad.” Which action should the nurse take first?

• a.Teach the client that skipping doses will worsen the breathing problem
• b.Document the client’s plan and reinforce the prescribed dosing schedule
• c.Give the client a list of pharmacies that may sell the inhaler for less
• d.Tell the provider that cost is blocking the client from taking it✓

Advocacy here means telling the prescriber that affordability is what is blocking adherence, so a therapeutically equivalent lower-cost drug or an assistance program can be considered before the client leaves. Repeating the teaching or listing pharmacies leaves the client holding a prescription they have already said they cannot afford.