Scope of Practice & Delegation
Which task can safely be delegated to a CNA?
A. Administering an oral medication
B. Assisting a client with ambulation after surgery
C. Teaching incentive spirometer use
D. Evaluating a client’s pain relief
B. Assisting a client with ambulation after surgery
The nurse’s duty toward a client with an advanced directive is to:
A. Disregard the document during emergencies
B. Ensure the document is placed in the chart and honored
C. Notify the family only
D. Contact the physician to void it
B. Ensure the document is placed in the chart and honored
A nurse threatens to restrain a client who refuses medication. This is:
ASSAULT
What does the “S” in SBAR stand for?
SITUATION
Which client should the nurse see first?
A. Stable client awaiting discharge
B. Client with blood sugar of 55 mg/dL
C. Client requesting pain meds
D. Post-op client voided once
B. Client with blood sugar of 55 mg/dL
The LPN can accept which task from the RN?
A. Initial assessment on a new admission
B. Titrating IV heparin infusion
C. Reinforcing teaching on insulin injection
D. Developing a nursing care plan
C. Reinforcing teaching on insulin injection
Which client statement indicates understanding of a healthcare directive?
A. “My family decides my care when I’m ill.”
B. “I can change this document at any time.”
C. “The nurse writes this form for me.”
D. “It expires in 6 months.”
B. “I can change this document at any time.”
A nurse gives medication after the client refused. This is:
BATTERY
Which is an example of a complete SBAR communication?
A. “Patient’s fine.”
B. “Situation: BP low; Background: on antihypertensive; Assessment: dizzy; Recommendation: hold medication.”
C. “Vitals dropping.”
D. “Patient refusing meds.”
B. “Situation: BP low; Background: on antihypertensive; Assessment: dizzy; Recommendation: hold medication.”
Which nursing action should be performed first?
A. Document morning vitals
B. Administer scheduled antibiotics
C. Check a patient complaining of chest pain
D. Review lab results
C. Check a patient complaining of chest pain
When delegating to a CNA, which instruction by the nurse is most appropriate?
A. “Record the client’s intake and output every hour.”
B. “Apply the client’s prescribed oxygen at 3 L/min.”
C. “Check the blood pressure after the antihypertensive.”
D. “Change the sterile dressing on the wound.”
A. “Record the client’s intake and output every hour.”
Which situation best represents autonomy?
A. Nurse explains the treatment plan without input
B. Client chooses whether to proceed with surgery
C. Family refuses treatment for the client
D. Physician decides what’s best for the clien
B. Client chooses whether to proceed with surgery
Posting negative comments about a patient online is:
LIBEL
Which practice maintains information technology security?
A. Sharing login credentials with coworkers
B. Logging off after documentation
C. Leaving the computer unlocked
D. Writing passwords on a sticky note
B. Logging off after documentation
The nurse completes an incident report after a fall. What is the next action?
A. Place it in the chart
B. Send to the risk management department per policy
C. Inform the family only
D. Destroy the report
B. Send to the risk management department per policy
Which nursing activity cannot be delegated to a CNA?
A. Turning and positioning a bed-bound client
B. Feeding a stable post-stroke client
C. Performing sterile wound care
D. Assisting a client with oral hygiene
C. Performing sterile wound care
Which nursing action upholds client confidentiality?
A. Discussing client status with visitors
B. Sharing information with a care conference
C. Leaving a chart open at the desk
D. Texting a coworker about the client
B. Sharing information with a care conference
A nurse suspects a coworker is impaired. What is the first action?
A. Ignore the situation
B. Confront the coworker privately
C. Report to the charge nurse or supervisor
D. Document in the client chart
C. Report to the charge nurse or supervisor
The nurse recognizes that informed consent is valid only when:
A. The client signs after medication administration
B. The nurse provides the detailed procedure explanation
C. The provider explains, and the client voluntarily agrees
D. The client signs a blank form before transfer
C. The provider explains, and the client voluntarily agrees
The nurse must contact which team member for a nutrition consult?
A. Physical therapist
B. Social worker
C. Registered dietitian
D. Pharmacist
C. Registered dietitian
The nurse delegates vital signs to a CNA. Which action requires follow-up?
A. CNA reports a BP of 88/52 but doesn’t notify the nurse
B. CNA rechecks a temperature before recording
C. CNA documents vitals on flow sheet
D. CNA informs nurse of pain rating 8/10
A. CNA reports a BP of 88/52 but doesn’t notify the nurse
Which nurse behavior best demonstrates advocacy?
A. Following physician orders without question
B. Encouraging the client to express preferences
C. Asking family to decide care
D. Avoiding discussion about options
B. Encouraging the client to express preferences
A nurse witnesses a coworker make a medication error and hide it. The best response is to:
A. Report the incident following policy
B. Wait for the coworker to self-report
C. Confront the coworker off duty
D. Ignore to preserve teamwork
A. Report the incident following policy
What should the nurse do if a coworker is performing an unsafe action?
A. Ignore unless harm occurs
B. Intervene immediately to prevent harm and report per policy
C. Wait until shift ends
D. Gossip about it with another nurse
B. Intervene immediately to prevent harm and report per policy
When a client expresses spiritual distress, the nurse should refer to:
A. The charge nurse
B. The chaplain or spiritual care provider
C. The dietitian
D. The physical therapist
B. The chaplain or spiritual care provider