Question Number 1 of 20
An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
A) "How long have you been a UAP and what units you have worked on?"
B) "What type of care do you give on the surgical unit and what ages of clients?"
C) "What is your comfort level in caring for children and at what ages?"
D) "Have you reviewed the list of expected skills you might need on this unit?"
The correct answer is D: "Have you reviewed the list of expected skills you might need on this unit?"
The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.
Question Number 2 of 20
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that
A) a referral is needed to the psychiatrist who is to provide the client with answers
B) the client has a right to know about the prescribed medications
C) such education is an independent decision of the individual nurse whether or not to teach clients about their medications
D) clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
The correct answer is B: The client has a right to know about the prescribed medications
Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.
A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to
A) keep the client’s room door cracked to minimize the distractions
B) assign 1 of the nursing staff to visit the client regularly
C) reassure the client that 1 staff person will check frequently if the client needs anything
D) arrange for each staff member to go into the client’s room to check on needs every hour on the hour
The correct answer is B: Assign 1 of the nursing staff to visit the client regularly
Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed.
Question Number 4 of 20
Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?
A) Be with a client who self-administers insulin
B) Cleanse and dress a small decubitus ulcer
C) Monitor a client's response to passive range of motion exercises
D) Apply and care for a client's rectal pouch
The correct answer is D: Apply and care for a client''s rectal pouch
The RN may delegate the application and care of rectal pouches to a UAP. This is an uncomplicated, routine task.
Question Number 5 of 20
After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying
A) "He has a lot of problems. You need to have patience with him."
B) "I will talk with him and try to figure out what to do."
C) "He may be scared and taking it out on you. Let's talk to figure out what to do."
D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."
The correct answer is C: "He may be scared and taking it out on you. Let''s talk to figure out what to do."
This response explains the client''s behavior without belittling the UAP’s feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem.
Question Number 6 of 20
Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."
B) "If the client is dizzy on standing, ask him to take some deep breaths."
C) "Assist the client to the bathroom at least twice on this shift."
D) "After you assist him to the chair, let me know how he feels."
The correct answer is A: "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."
Give clear information to the UAP about what is expected for client safety.
Question Number 7 of 20
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
A) a Dopamine drip IV with vital signs monitored every 5 minutes
B) a myocardial infarction that is free from pain and dysrhythmias
C) a tracheotomy of 24 hours in some respiratory distress
D) a pacemaker inserted this morning with intermittent capture
The correct answer is B: A myocardial infarction that is free from pain and dysrhythmias
This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client.
Question Number 8 of 20
The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?
A) Encourage oral fluids to prevent dehydration
B) Recheck temperature 15 minutes after removing hot liquids from the bedside
C) Ask the client to drink only cold water and juices
D) Chart this temperature elevation on the flow sheet
The correct answer is B: Recheck temperature 15 minutes after removing hot liquids from the bedside
Recheck temperature to eliminate possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading. Avoid premature assumptions about explanations for findings. The other options are incorrect.
Question Number 9 of 20
A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first
A) focus on reality orientation to place and person
B) assist with the report of the client’s complaint to the police
C) obtain more details of the client’s claim of abuse
D) document the statement on the client’s chart with a report to the manager
The correct answer is C: Obtain more details of the client’s claim of abuse
The advocacy role of the professional nurse as well as the legal duty of the reasonable prudent nurse requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, further assessment, before documentation or the reporting of the complaint.
Question Number 10 of 20
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
A) normal patterns of behavior may be labeled as deviant, immoral, or insane
B) the meaning of the client's behavior can be derived from conventional wisdom
C) personal values will guide the interaction between persons from 2 cultures
D) the nurse should rely on her knowledge of different developmental mental stages
The correct answer is A: Normal patterns of behavior may be labeled as deviant, immoral, or insane
Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
Question Number 11 of 20
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)?
A) Test a stool specimen for occult blood
B) Assist with the ambulation of a client with a chest tube system
C) Irrigate and redress a leg wound
D) Admit a client from the emergency room
The correct answer is C: Irrigate and redress a leg wound
The PN is a licensed provider and can perform this complex task. Options A and B could be delegated to an unlicensed assistive personnel (UAP), and option D requires an RN.
Question Number 12 of 20
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements?
A) "I am sorry. Referral information can only be provided by the client’s providers"
B) "I can never give any information out by telephone. How do I know who you are?"
C) "Since this is a referral, I can give you this information"
D) "I need to get the client’s written consent before I release any information to you"
The correct answer is D: "I need to get the client’s written consent before I release any information to you"
In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared.
Question Number 13 of 20
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
A) To observe the type and amount of nasogastric tube drainage
B) Monitor the client for nausea or other complications
C) Irrigate the nasogastric tube with the ordered irrigant
D) Perform nostril and mouth care
The correct answer is D: Perform nostril and mouth care
Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks would be appropriate for a PN or RN to do since they are advanced skills or require evaluation.
Question Number 14 of 20
A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to
A) ask to not be assigned to this client or to work on another unit
B) tell the client that such behavior is inappropriate
C) inform the client that hospital policy prohibits staff to date clients
D) discuss the boundaries of the therapeutic relationship with the client
The correct answer is D: Discuss the boundaries of the therapeutic relationship with the client
The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
Question Number 15 of 20
The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning which of these tasks to a UAP indicates the student needs further teaching about the delegation process?
A) Assist a client post cerebral vascular accident to ambulate
B) Feed a 2 year-old in balanced skeletal traction
C) Care for a client with discharge orders
D) Collect a sputum specimen for acid fast bacillus
The correct answer is C: Care for a client with discharge orders
A registered nurse (RN) is the best person to do teaching or evaluation that is needed at time of discharge.
Question Number 16 of 20
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client
A) has had a change in respiratory rate by an increase of 2 breaths
B) has had a change in heart rate by an increase of 10 beats
C) was minimally responsive to voice and touch
D) has had a blood pressure change by a drop in 8 mmHg systolic
The correct answer is C: was minimally responsive to voice and touch
A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse. The other changes could occur within the range of normal fluctuations.
Question Number 17 of 20
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
A) "I must document and report any information."
B) "I can’t make such a promise."
C) "That depends on what you tell me."
D) "I must report everything to the treatment team."
The correct answer is B: "I can’t make such a promise."
Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality
Question Number 18 of 20
The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?
A) Test blood sugar every 2 hours by Accu-Check
B) Review with family and client signs of hyperglycemia
C) Monitor for mental status changes
D) Check skin condition of lower extremities
Your response was "A".
The correct answer is A: Test blood sugar every 2 hours by Accu-Check
The UAP can do standard, unchanging procedures.
Question Number 19 of 20
The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
A) Assign an RN to provide total care of the client
B) Assign a nursing assistant to help the client with self-care activities
C) Delegate complete care to an unlicensed assistive personnel
D) Supervise a nursing assistant for skin care
Your response was "A".
The correct answer is D: Supervise a nursing assistant for skin care
The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.
Question Number 20 of 20
A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?
A) A 76-year-old client with severe depression
B) A middle-aged client with an obsessive compulsive disorder
C) An adolescent with dehydration and anorexia
D) A young adult who is a heroin addict in withdrawal with hallucinations
The correct answer is B: A middle-aged client with an obsessive compulsive disorder
The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition