Delegation
Pain
Hypertension
Perioperatative
Sensory
100

A nurse is working with an unlicensed assistive personnel (UAP) on a busy medical-surgical floor. Which task can the nurse safely delegate to the UAP?

  1. Assessing a patient’s level of pain post-operatively.
  2. Administering a dose of oral acetaminophen.
  3. Assisting a stable patient with ambulation.
  4. Educating a patient on discharge instructions.

3. Assisting a stable patient with ambulation. 

100

A nurse is preparing to assess a patient's pain level. Which question will provide the most comprehensive assessment of the patient's pain?

  1. "On a scale of 0 to 10, how would you rate your pain?"
  2. "Is your pain constant or does it come and go?"
  3. "Can you describe the quality of your pain?"
  4. "What does your pain feel like, and what makes it better or worse?

4. "What does your pain feel like, and what makes it better or worse?"

100

A nurse is reviewing a patient’s blood pressure readings to assess for hypertension. Which blood pressure range indicates Stage 1 hypertension?

  1. 120-129 mmHg systolic and less than 80 mmHg diastolic
  2. 130-139 mmHg systolic or 80-89 mmHg diastolic
  3. 140-159 mmHg systolic or 90-99 mmHg diastolic
  4. 160 mmHg systolic or higher, or 100 mmHg diastolic or higher

2. 130-139 mmHg systolic or 80-89 mmHg diastolic

100

A nurse is reviewing the types of anesthesia used for a surgical procedure. Which of the following statements correctly describes the difference between general anesthesia, regional anesthesia, and local anesthesia?

  1. "General anesthesia involves the use of local anesthetics to block nerve impulses in a specific area of the body."
  2. "Regional anesthesia numbs a specific area of the body, and the patient remains conscious."
  3. "Local anesthesia involves the use of inhaled medications to induce unconsciousness for surgery."
  4. "General anesthesia induces a state of unconsciousness and is used for major surgeries, while regional anesthesia numbs a larger area of the body."

4. "General anesthesia induces a state of unconsciousness and is used for major surgeries, while regional anesthesia numbs a larger area of the body."

100

A nurse is assessing a patient who has been in the hospital for several days. The patient reports feeling anxious, unable to focus, and overwhelmed by the constant noise from machines and visitors. Based on these symptoms, which diagnosis is most likely?

  1. Sensory deprivation
  2. Sensory overload
  3. Acute confusion
  4. Anxiety disorder

2. Sensory overload

200

The charge nurse is planning assignments for the day. Which task is appropriate for a licensed practical nurse (LPN) to complete?

  1. Developing a care plan for a newly admitted patient with diabetes.
  2. Starting an intravenous (IV) line in a patient who needs fluid resuscitation.
  3. Conducting an initial assessment on a patient admitted for chest pain.
  4. Monitoring and documenting intake and output for a stable patient with heart failure.

4. Monitoring and documenting intake and output for a stable patient with heart failure.

200

A patient with rheumatoid arthritis complains of joint pain that worsens in the morning and improves throughout the day. The nurse plans care based on the understanding of which pain pattern?

  1. Chronic pain, due to its persistence over time.
  2. Acute pain, because it intensifies with movement.
  3. Nociceptive pain, due to inflammation of the joints.
  4. Neuropathic pain, due to nerve damage in the joints.

1. Chronic pain, due to its persistence over time.

200

The nurse is educating a patient who has been diagnosed with Stage 2 hypertension. Which blood pressure reading would fall under this category?

  1. 110/70 mmHg
  2. 128/78 mmHg
  3. 138/84 mmHg
  4. 146/92 mmHg

4. 146/92 mmHg

200

A nurse is preparing a patient for surgery and needs to ensure that informed consent has been obtained. Which of the following actions is the nurse's responsibility regarding the informed consent process?

  1. Ensure that the patient has signed the consent form before administering preoperative medications.
  2. Explain the risks and benefits of the surgery to the patient before obtaining their signature.
  3. Obtain the patient's signature on the consent form after the surgeon explains the procedure.
  4. Witness the patient’s signature on the consent form, ensuring the patient understands the procedure.


4. Witness the patient’s signature on the consent form, ensuring the patient understands the procedure.

200

A nurse is caring for an elderly patient who has been confined to a bed in a quiet room with little interaction for several days. The patient appears disoriented, restless, and reports difficulty sleeping. Which condition does the nurse suspect?

  1. Sensory overload
  2. Sensory deprivation
  3. Acute confusion
  4. Delirium

2. Sensory deprivation

300

A nurse is assigning tasks for the day to a UAP. Which of the following tasks is NOT appropriate to delegate to the UAP?

  1. Measuring and recording a patient’s vital signs.
  2. Helping a patient with feeding.
  3. Turning and positioning an immobile patient every 2 hours.
  4. Changing the sterile dressing on a surgical wound.

4. Changing the sterile dressing on a surgical wound

300

A patient is receiving morphine through a patient-controlled analgesia (PCA) pump following surgery. The patient tells the nurse, "I'm afraid to push the button too much because I don’t want to get addicted." What is the best response by the nurse?

  1. "Let me call the provider to discuss an alternative pain management option."
  2. "You can press the button whenever you feel pain. It’s better to control it before it gets severe."
  3. "It’s normal to be afraid of addiction, but the risk is very low with short-term use."
  4. "You shouldn't press it too often; try to use other methods for pain control instead."

2. "You can press the button whenever you feel pain. It’s better to control it before it gets severe."

300

The nurse is educating a patient about hypertension risk factors. Which statement by the patient indicates an understanding of the difference between nonmodifiable and modifiable risk factors for hypertension?

  1. "My family history of hypertension is a modifiable risk factor because I can work to prevent it."
  2. "My age is a nonmodifiable risk factor, while my diet and activity level are modifiable."
  3. "Smoking and high cholesterol are nonmodifiable factors that I need to manage."
  4. "Since stress and obesity are nonmodifiable factors, I’ll focus on other ways to lower my blood pressure.

2. "My age is a nonmodifiable risk factor, while my diet and activity level are modifiable."

300

A nurse is preparing a patient for surgery and reviews the classification of the procedure. Which of the following is the correct classification for a surgery that is performed to remove a tumor that is affecting the function of an organ?

  1. Elective surgery
  2. Diagnostic surgery
  3. Curative surgery
  4. Palliative surgery

3. Curative surgery

300

A nurse is caring for a patient with visual impairment. Which of the following interventions is most appropriate to ensure the patient’s safety and comfort during a hospital stay?

  1. Leave the patient’s room door open at all times to allow them to hear sounds from the hallway.
  2. Speak in a loud voice to ensure the patient can hear instructions clearly.
  3. Use clear, descriptive language to explain the environment and any changes in the patient's surroundings.
  4. Place the patient’s belongings in a random location so they can navigate independently.

3. Use clear, descriptive language to explain the environment and any changes in the patient's surroundings.

400

A nurse working in a rehabilitation center is delegating tasks to an experienced UAP. Which task is appropriate for the UAP to perform?

  1. Administering scheduled oral medications.
  2. Performing a focused respiratory assessment on a patient with pneumonia.
  3. Assisting a patient with bathing and dressing.
  4. Developing a teaching plan for a patient with a new ostomy

3. Assisting a patient with bathing and dressing.

400

PCA Ordered: Morphine 1mg/mL in 30 mL syringe
Loading dose: 0
Continuous Dose: 2 mg/hr
Demand dose: 0.5 mg
Lockout: 5 minutes
4 hour limit: 40 mg

What is the maximum dose that the client could possibly receive in 1 hour?

8 mg

400

A nurse is explaining hypertension classifications to a patient. Which statement made by the patient indicates understanding?

  1. "A normal blood pressure is below 130/80 mmHg."
  2. "Stage 1 hypertension means my blood pressure is over 140/90 mmHg."
  3. "Elevated blood pressure is between 120 and 129 systolic with a diastolic less than 80."
  4. "Stage 2 hypertension is defined as a blood pressure of 130-139 over 80-89."


3. "Elevated blood pressure is between 120 and 129 systolic with a diastolic less than 80."

400

A patient is undergoing surgery under general anesthesia, and the surgical team notices an abrupt increase in body temperature, muscle rigidity, and tachycardia. The nurse suspects malignant hyperthermia. Which of the following actions is the nurse's priority?

  1. Administer a dose of dantrolene sodium as ordered.
  2. Increase the patient's intravenous fluid rate to promote cooling.
  3. Lower the operating room temperature and apply ice packs to the patient.
  4. Administer oxygen at 100% via a non-rebreather mask.

1. Administer a dose of dantrolene sodium as ordered.

400

A nurse is caring for a patient with hearing impairment. Which of the following actions should the nurse take to improve communication with the patient?

  1. Speak slowly and loudly, ensuring that the patient can hear every word clearly.
  2. Use written instructions and ensure the patient has their hearing aids in place.
  3. Avoid making eye contact with the patient, as it may cause discomfort.
  4. Use complex medical terminology to ensure clarity and accuracy of the message.

2. Use written instructions and ensure the patient has their hearing aids in place.

500

A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on a busy medical-surgical unit. The RN reviews the "Five Rights of Delegation" to ensure tasks are assigned appropriately. Which action by the RN demonstrates an understanding of the "Right Person" in delegation?

  1. Assigning the UAP to perform a sterile dressing change on a post-operative patient.
  2. Asking the LPN to monitor vital signs and report any abnormalities for a patient on a cardiac monitor.
  3. Delegating the task of assessing pain levels in a post-operative patient to the UAP.
  4. Instructing the UAP to administer a PRN medication for a patient with a headache.

2. Asking the LPN to monitor vital signs and report any abnormalities for a patient on a cardiac monitor.

500

A nurse is caring for a patient with cancer who has been receiving opioid analgesics for pain control. The patient reports no significant pain relief and appears increasingly agitated. What is the nurse's best action?

  1. Explain that it may take time for the medication to work.
  2. Contact the provider to discuss increasing the opioid dose or switching to another pain control method.
  3. Instruct the patient to try relaxation techniques before adjusting medications.
  4. Document the patient's complaints and plan to reassess later.

2. Contact the provider to discuss increasing the opioid dose or switching to another pain control method.

500

A patient arrives at the emergency department with a blood pressure reading of 186/118 mmHg and reports a severe headache but denies any chest pain, shortness of breath, or vision changes. The nurse suspects hypertensive urgency. Which is the priority intervention for this patient?

  1. Administer antihypertensive medications to rapidly lower blood pressure.
  2. Provide education on lifestyle modifications to manage blood pressure.
  3. Administer oral antihypertensive medication to gradually reduce blood pressure over 24-48 hours.
  4. Prepare the patient for admission to the intensive care unit (ICU) for close monitoring.

3. Administer antihypertensive medication to gradually reduce blood pressure over 24-48 hours.

500

A 17-year-old male is post-op after a knee surgery. After
administration of morphine, the nurse notices the client’s
blood pressure has dropped to 86/40 and his RR is 8. Which
should the nurse anticipate after informing the surgeon of the vital
sign changes?
1. Administering Naloxone (Narcan)
2. Administering Morphine
3. Giving a 500 mL NS bolus
4. Stopping the procedure


1. Administering Naloxone (Narcan)

500

A patient recovering from surgery reports seeing objects
that are not present. The nurse recognizes that the
patient may be experiencing hallucinations. What is the
appropriate nursing action?
1. Agree with the patient to reduce their anxiety.
2. Tell the patient that the hallucinations are not real.
3. Acknowledge the patient's feelings and provide reassurance.
4. Administer sedatives to calm the patient.


3. Acknowledge the patient's feelings and provide reassurance.

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