An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the 

following assignments should the LPN question?

D. Replacing the cartridge and tubing on a PCA pump

Rationale: The RN is responsible for the PCA pump

A nurse is preparing an in-service program about delegation. Which of the following elements

should she identify when presenting the 5 rights of delegation? Select all.

B. Right supervision/evaluation

C. Right direction/communication

E. Right circumstances

Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia?

Yes.

A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the 

following client's needs may the nurse assign to a assistive personnel (AP)?

C. Reapplying a condom catheter for a client who has urinary incontinence

Rationale: The application of a condom catheter is a noninvasive, routine procedure that the

nurse may delegate to the AP

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of 

the following information should the nurse share with the AP? Select All.

B. The client ambulates w/his slippers on over his antiembolic stockings

C. The client uses a front-wheeled walker when ambulating

D. The client had pain medication 30 min ago

A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is 

awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member 

should the nurse assign to this client?

RN

Rational: A client returning from surgery requires assessment and establishment of a plan of

care. RNs are responsible for this, especially if the client is potentially unstable.

A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will 

put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is 

the AP committing?

A. Assault

Rational: By threatening the client, the AP is committing assault.

An adult client who is competent tells the nurse that he is thinking about leaving the hospital

against medical advice. The nurse believes that this is not in the client's best interest, so she

administers a PRN sedative med that the client has not requested along w/his usual meds.

Which of the following tort has the nurse committed?

B. False imprisonment

Rational: The nurse gave the med as a chemical restraint to keep the client from leaving the

facility against medical advice. The client did not consent.

A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he 

will prepare his advance directives before he goes to the hospital. Which of the following statements by 

the client indicates to the nurse that he understands advance

directives?

C. "I plan to write that I don't want them to keep me on a breathing machine."

Rational: The client has the right to decide and specify which medical procedures he wants

when a life-threatening situation arrives

A client is about to undergo an elective surgical procedure. Which of the following actions are

appropriate for the nurse who is providing pre-op care regarding informed consent? Select all.

A. Make sure the surgeon obtained the client's consent

B. Witness the client's signature on the consent form

Rational: The rest of the choices are the surgeon's responsibility, not the nurse

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & 

unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when 

she was not on break. Which of the following actions should the nurse take?

Rational: Any nurse who notices behavior that could possibly jeopardize client care or indicate a 

substance abuse problem has a duty to report the situation immediately to the nurse manager

A nurse is preparing info for a change-of-shift report. Which of the following info should the

nurse include in the report?

C. A bone scan that is scheduled for today

Rational: This is important because the nurse might have to modify the client's care to

accommodate them leaving the unit

A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but

I got myself back up & into my chair." How should the nurse document this in the client's chart?

B. The nurse should not document this info because she did not witness the fall

Rational: By writing what the client states, the info is subjective data