Vermont PN: Coordinated Care Practice Test

Practice test questions — PN: Coordinated Care

1. Which task is most appropriate for an LPN/LVN to perform under the supervision of an RN?

   • Develop the initial nursing care plan for a newly admitted client
   • Reinforce client teaching from a plan that the RN has already developed and initiated ✓
   • Conduct the initial admission assessment of a complex postoperative client
   • Perform triage in the emergency department

   LPN/LVN scope of practice is more limited than RN scope. The RN is responsible for INITIAL assessments, developing care plans, and providing initial teaching. The LPN's role is to REINFORCE existing teaching, contribute to data collection, and provide care within established plans. Key LPN scope pri…

2. An LPN is caring for four clients. Which client should the LPN see first?

   • A client requesting pain medication 3 hours after last dose
   • A client with new-onset shortness of breath and chest pain ✓
   • A client needing assistance with morning hygiene
   • A client asking about discharge instructions

   Priority-setting questions are heavily tested on NCLEX-PN. Use the ABC framework: Airway, Breathing, Circulation. The client with new-onset shortness of breath and chest pain has potential airway/breathing/circulation compromise — this could be MI, PE, pulmonary edema, or another life-threatening em…

3. Which infection control precautions are appropriate for a client with active tuberculosis (TB)?

   • Standard precautions only
   • Airborne precautions: private negative-pressure room, N95 respirator for staff, door kept closed, client wears surgical mask when leaving the room ✓
   • Contact precautions: gown and gloves
   • Droplet precautions: surgical mask only

   Transmission-based precautions for NCLEX-PN: (1) AIRBORNE — for organisms transmitted by very small droplet nuclei suspended in air: TB, measles, varicella (chickenpox), disseminated zoster, COVID-19 in high-risk procedures, SARS, MERS. Requires: private NEGATIVE-PRESSURE room with door closed, N95 …

4. What is the correct procedure for using restraints on a client?

   • Apply restraints whenever a client is confused
   • Use only as a last resort with a physician's order, the least restrictive type effective, with frequent (every 15-30 min) checks, regular release for ROM and toileting, documented justification, and time-limited orders ✓
   • Tie restraints to side rails for security
   • Apply restraints permanently

   Restraint use is heavily regulated due to patient safety, dignity, and legal concerns. CMS, Joint Commission, and state laws require strict protocols. Key principles: (1) LAST RESORT — only after less restrictive measures (reorientation, distraction, family presence, bed/chair alarms, environmental …

5. Which is the highest priority action when a fire is discovered in a healthcare facility?

   • Call 911 first
   • Use the RACE acronym in order: Rescue clients in immediate danger, Alarm (pull fire alarm, notify staff), Contain (close doors and windows), Extinguish (only if small and safe to do so) or Evacuate ✓
   • Fight the fire personally
   • Lock all doors

   Fire safety in healthcare facilities uses the RACE acronym: R = RESCUE — clients in immediate danger first; move ambulatory clients first, then assistive clients, then non-ambulatory; A = ALARM — pull the nearest fire alarm, dial the facility emergency code, notify other staff; C = CONTAIN — close d…

6. Which task can the LPN appropriately delegate to a Certified Nursing Assistant (CNA/UAP)?

   • Administering oral medications
   • Taking routine vital signs on a stable client and recording oral intake/output ✓
   • Performing the initial wound assessment
   • Teaching the client about a new medication

   Delegation to Unlicensed Assistive Personnel (UAP/CNA) follows the 'Five Rights of Delegation' (NCSBN): RIGHT TASK, RIGHT CIRCUMSTANCE, RIGHT PERSON, RIGHT DIRECTION/COMMUNICATION, RIGHT SUPERVISION. UAPs CAN typically perform: routine vital signs on stable clients; bathing/hygiene/ADLs; ambulation …

7. A UAP reports that a stable post-op client's vital signs are: BP 138/82, HR 88, RR 18, T 99.2°F. What should the LPN do?

   • Ignore the report
   • Acknowledge the report, note the values are within expected range for this client, document, and continue monitoring per orders ✓
   • Have the UAP retake the vitals
   • Call the surgeon immediately

   Effective delegation requires the nurse to receive, evaluate, and act on UAP reports. These vitals are within normal/expected ranges: BP 138/82 (slightly elevated but not concerning in immediate post-op), HR 88, RR 18, T 99.2°F (mild post-op temperature is common from inflammation, atelectasis, or s…

8. Which is the BEST example of correct nursing documentation?

   • Client seems uncomfortable today
   • Client reports pain 7/10 in surgical site, sharp and constant, worsens with movement; grimacing observed; medicated with morphine 4 mg IV as ordered at 1045 ✓
   • Client is doing fine
   • Client appears to be getting better

   Documentation principles: (1) OBJECTIVE — what you see, measure, hear, smell; not what you infer or feel; (2) SPECIFIC — exact measurements, locations, times, doses; (3) FACTUAL — direct quotes from client when appropriate; (4) TIMELY — document as soon as possible after care; (5) COMPLETE — address…

9. A client refuses a prescribed medication, stating they don't want it. What is the BEST nursing response?

   • Force the client to take the medication
   • Respect the client's right to refuse, explore the reason for refusal, provide education about the medication's purpose and consequences of refusal, document the refusal and teaching, notify the prescriber ✓
   • Sneak the medication in food
   • Ignore the refusal and document as 'medication given'

   Client autonomy is a fundamental right protected by law and ethics. Competent adult clients have the right to refuse any treatment, even if refusal leads to harm or death (with limited exceptions like emergency life-saving treatment of unconscious patients, court-ordered treatment, public health eme…

10. What is the correct procedure when obtaining informed consent for a surgical procedure?

    • The nurse explains the procedure and obtains consent
    • The physician/surgeon explains the procedure, risks, benefits, alternatives; the nurse witnesses the signature, confirms client understanding, and ensures the consent is in the chart before the procedure ✓
    • Family members sign for adult clients
    • Verbal consent is sufficient

    Informed consent has specific legal requirements. Elements of valid informed consent: (1) The client must be COMPETENT (legal capacity to consent — adults presumed competent unless determined otherwise; minors generally cannot consent, parent/guardian does; cognitively impaired adults may have surro…

11. What is the most important nursing intervention to prevent the spread of infection in a healthcare setting?

    • Wearing gloves at all times
    • Hand hygiene — frequent handwashing with soap and water, or alcohol-based hand sanitizer, performed before and after every client contact and per WHO's 5 moments of hand hygiene ✓
    • Isolating all clients
    • Sterile technique for all care

    Hand hygiene is THE single most effective infection prevention measure — repeatedly documented in research. WHO's 5 Moments of Hand Hygiene: (1) BEFORE touching a patient; (2) BEFORE clean/aseptic procedure; (3) AFTER body fluid exposure risk; (4) AFTER touching a patient; (5) AFTER touching patient…

12. Using the SBAR communication framework, what is the correct order of information when reporting to a physician?

    • Random order based on what comes to mind
    • Situation (what's happening now), Background (relevant history/context), Assessment (your clinical findings/concerns), Recommendation (what you're requesting) ✓
    • Recommendation first, then everything else
    • Only assessment, no other information

    SBAR is the standard structured communication framework in healthcare, especially for nurse-to-physician reports, handoffs, and urgent situations. S = SITUATION — brief statement of the immediate problem: 'I'm calling about Mr. Smith in 412, who has new shortness of breath.' B = BACKGROUND — relevan…

13. An error is made in documenting on a paper chart. What is the correct procedure to correct it?

    • Erase the error
    • Draw a single line through the error so it remains readable, write 'error' or 'mistaken entry' above it, initial and date the correction, then write the correct entry ✓
    • Use white-out to cover the error
    • Tear out the page

    Paper chart corrections follow specific legal procedures because the chart is a legal document. Correct method: (1) Single line through the error — DO NOT scribble out, erase, or use white-out; the original entry must remain readable; (2) Write 'error,' 'mistaken entry,' or 'wrong patient' near the …

14. Which is an example of a HIPAA violation?

    • Documenting in the medical record
    • Discussing a client's diagnosis in a public hallway where visitors can overhear, or accessing the chart of a celebrity patient out of curiosity, or sharing client information on social media ✓
    • Reporting communicable diseases to public health
    • Sharing information with other care team members involved in the client's treatment

    HIPAA (Health Insurance Portability and Accountability Act of 1996) protects patient health information (PHI). Common HIPAA violations: (1) PUBLIC DISCUSSIONS — talking about clients in hallways, elevators, cafeterias, or anywhere unauthorized people can overhear; (2) SOCIAL MEDIA — posting any clie…

15. Which task should the LPN NOT delegate to a UAP?

    • Bathing a stable client
    • Initial assessment of a newly admitted unstable client with chest pain ✓
    • Measuring intake and output
    • Assisting with ambulation

    UAPs cannot perform initial assessments — especially of unstable clients. Initial assessment requires nursing judgment to identify problems, prioritize, and determine interventions. A client with chest pain has potential life-threatening conditions (MI, PE, dissection, pneumothorax) requiring traine…

16. A client expresses suicidal ideation with a plan and means available. What is the priority nursing action?

    • Wait until next shift to address
    • Notify the charge nurse and provider immediately, implement constant observation (1:1 sitter), remove access to means of self-harm, document, and ensure mental health evaluation is initiated ✓
    • Tell the client to stop talking about it
    • Give the client privacy

    Suicide risk with PLAN + MEANS is a psychiatric emergency requiring immediate intervention. Risk assessment (SAD PERSONS or other tools): higher risk with (S)ex (male higher completion), (A)ge (older), (D)epression, (P)revious attempts, (E)thanol/drug use, (R)ational thinking loss, (S)ocial support …

17. Which is the correct procedure when administering medications?

    • Give medications quickly to save time
    • Follow the 'Rights of Medication Administration': Right Patient (2 identifiers), Right Medication, Right Dose, Right Route, Right Time, Right Documentation; verify allergies, check expiration, assess for contraindications, monitor for response ✓
    • Skip verification if you're sure
    • Give medications based on what the patient requests

    Medication errors are a leading cause of preventable harm in healthcare. The 'Rights of Medication Administration' (originally 5, expanded to 6-10 depending on source) provide a verification framework: (1) RIGHT PATIENT — two identifiers (name + DOB, name + MRN); never use room number; ask client to…

18. What information is essential to include in a shift-end handoff report?

    • Only the client's diagnosis
    • Patient identifiers, current condition and assessment findings, recent changes, current treatments and medications (especially recent and PRN administrations), upcoming orders/tests, pending issues requiring follow-up, family concerns, code status, isolation precautions ✓
    • Personal opinions about the patient
    • The previous nurse's mistakes

    Handoff is one of the highest-risk moments for communication errors and patient harm. Joint Commission and CMS focus heavily on standardized handoff. Essential information to communicate: (1) IDENTIFIERS — name, room, age, diagnoses; (2) CODE STATUS — full code, DNR, DNI, comfort care, with date of …

19. What is the nurse's role as a client advocate?

    • Make decisions for the client
    • Support the client's autonomy and informed decision-making; provide accurate information; speak up when the client's wishes, rights, or safety are at risk; ensure access to resources; navigate the healthcare system on the client's behalf when needed ✓
    • Always agree with the physician
    • Stay neutral and don't get involved

    Client advocacy is a core nursing responsibility. The American Nurses Association (ANA) Code of Ethics emphasizes the nurse's role in protecting client rights, dignity, and well-being. Advocacy includes: (1) AUTONOMY SUPPORT — respecting client decisions about their own care, even when nurse disagre…

20. Using the ABC framework, what is the priority assessment for any client?

    • Skin assessment
    • Airway (patent and protected), Breathing (rate, depth, effort, oxygenation), Circulation (pulse, BP, perfusion, bleeding) — in that order ✓
    • Bowel sounds
    • Mental status only

    ABC (Airway, Breathing, Circulation) is the foundational priority framework in nursing and emergency care. The order reflects time-to-death: without airway, death in 4-6 minutes (brain damage starts in 3 min); without breathing, similar; without circulation, similar but slightly longer. A — AIRWAY: …

21. A client is scheduled for discharge. Which member of the interdisciplinary team is MOST appropriate to coordinate referrals for home health services and community resources?

    • The LPN/LVN
    • The social worker — they have expertise in community resources, insurance coverage, home health agency selection, and can coordinate the complex logistics of post-discharge care ✓
    • The hospital administrator
    • The dietary aide

    INTERDISCIPLINARY TEAM COORDINATION and knowing when to involve each team member is a core NCLEX-PN coordinated care competency. SOCIAL WORKER ROLE in discharge planning: INSURANCE AND BENEFITS: expertise in Medicare, Medicaid, private insurance coverage for home health, skilled nursing facility, an…

22. A nurse is caring for a client with active pulmonary tuberculosis (TB). Which type of transmission-based precautions are required?

    • Contact precautions only
    • Airborne precautions — including a negative pressure isolation room (airborne infection isolation room/AIIR) and N95 respirator (not a surgical mask) for all healthcare workers entering the room ✓
    • Droplet precautions
    • Standard precautions alone

    TRANSMISSION-BASED PRECAUTIONS are used in addition to standard precautions for clients with known or suspected specific infectious diseases. THREE TYPES based on route of transmission: (1) CONTACT PRECAUTIONS: for diseases spread by direct or indirect contact (touching the patient or contaminated s…

23. An LPN is asked to delegate a task to an unlicensed assistive personnel (UAP). Which task is APPROPRIATE to delegate?

    • Administering oral medications to a stable client
    • Measuring and recording vital signs for a stable post-operative client on day 2 ✓
    • Inserting a urinary catheter
    • Teaching a diabetic client about insulin injection technique

    DELEGATION PRINCIPLES for LPN/LVN: The LPN/LVN may delegate tasks to UAPs (nursing assistants, patient care technicians, aides) that are within the UAP's scope of training and the state practice act, AND that fall within the 'routine care' category. DELEGATION DECISION FRAMEWORK — consider: (1) TASK…

24. A nurse is preparing to administer a medication using the 10 rights of medication administration. Which 'right' is the nurse verifying when they ask the client to state their name and date of birth?

    • Right medication
    • Right client (right patient) — verifying the client's identity using two identifiers before any medication administration ✓
    • Right dose
    • Right time

    The 10 RIGHTS OF MEDICATION ADMINISTRATION provide a framework for safe drug administration. Asking the client to state their name and date of birth verifies the RIGHT CLIENT (also called right patient). THE 10 RIGHTS: (1) RIGHT CLIENT: verify identity using TWO identifiers per Joint Commission stan…

25. An LPN is caring for a stable client with hypertension on a medical-surgical unit and notices the client's blood pressure is 168/102 mmHg — significantly higher than the client's recent baseline of 130/82 mmHg. What is the PRIORITY action?

    • Wait until the next scheduled vital sign check to see if it normalizes
    • Report the finding to the supervising RN immediately along with any associated symptoms (headache, visual changes, chest pain, confusion) — a significant change from baseline requires prompt RN notification and provider assessment ✓
    • Administer an additional dose of the client's antihypertensive independently
    • Document only and re-check in 4 hours

    RECOGNIZING AND REPORTING SIGNIFICANT CHANGES is the most fundamental PN nursing responsibility. A blood pressure of 168/102 in a client whose baseline is 130/82 represents a clinically significant CHANGE FROM BASELINE that requires prompt assessment. WHY THIS IS A PRIORITY REPORT: (1) The CHANGE MA…

26. A patient has C. difficile (C. diff) infection. Which isolation precaution level is required?

    • Airborne precautions
    • Contact precautions — C. diff spreads via the fecal-oral route through spores that survive on surfaces; requires gloves and gown, dedicated equipment, and hand washing with SOAP AND WATER (not alcohol gel) ✓
    • Droplet precautions
    • Standard precautions only

    C. DIFFICILE requires CONTACT PRECAUTIONS: Private room or cohorting; gloves AND gown when entering the room; dedicated equipment (thermometer, stethoscope, BP cuff — not shared); HAND HYGIENE with SOAP AND WATER — alcohol-based hand sanitiser is NOT effective against C. diff spores. This is the mos…

27. A patient is ordered NPO (nothing by mouth) after midnight for morning surgery. The patient asks for their routine blood pressure medication at 6 AM. What should the nurse do?

    • Withhold all medications — NPO means nothing by mouth
    • Clarify the order with the surgeon or anaesthesiologist — many medications (especially antihypertensives, cardiac drugs, and seizure medications) are specifically ordered to be given WITH A SIP OF WATER even when NPO for surgery; never assume ✓
    • Give all routine medications with a full glass of water
    • Hold only solid food; give all medications as ordered

    NPO FOR SURGERY typically means NPO after midnight for solid foods. Many surgical NPO orders specifically state 'NPO except medications with sip of water' or list specific medications to continue. For antihypertensives specifically: uncontrolled hypertension creates surgical risk — most anaesthesiol…

28. The LPN is caring for 5 patients. Which task is MOST appropriate to delegate to a certified nursing assistant (CNA)?

    • Assessing a new patient's pain level
    • Administering an oral medication
    • Assisting a stable patient with morning hygiene and bathing ✓
    • Inserting a urinary catheter

    DELEGATION TO CNA: CNAs perform tasks within their scope: assistance with ADLs (bathing, grooming, dressing, ambulation, feeding); vital signs (after training and competency verification); toileting assistance; positioning; reporting observations to the nurse. WHAT CNAs CANNOT DO: assessment (evalua…

29. A nurse is preparing to give insulin for the first time on a new unit. What safety check is critical BEFORE administering any insulin?

    • Check the patient's name only
    • Verify insulin type, dose, and timing with a second licensed nurse per facility policy — insulin is a high-alert medication; double-check the type (Regular, NPH, Glargine, etc.), dose in units, and timing (before meal, at bedtime) to prevent dosing errors ✓
    • Check the meal tray is at the bedside
    • Verify blood glucose only after administration

    INSULIN DOUBLE-CHECK is a safety standard in most facilities because insulin errors are common and dangerous. What to verify: TYPE — insulin types look similar but have vastly different durations and onset times; NPH and Regular insulin are often confused; Lantus (glargine) is a 24-hour insulin that…

30. A patient has soft wrist restraints ordered. How frequently must the nurse document assessment of the restrained extremities?

    • Every 8 hours
    • Every 4 hours
    • At minimum every 1-2 hours (per most facility policies and TJC/CMS standards) — check circulation, sensation, and skin integrity; provide ROM exercises; offer toileting and hydration; document assessment ✓
    • Only when something seems wrong

    RESTRAINT MONITORING REQUIREMENTS: Facilities must comply with Joint Commission (TJC) and CMS standards for patients in restraints. MINIMUM STANDARDS: Assessment every 1-2 hours; WHAT TO ASSESS EACH TIME: Circulation (pulses, capillary refill, colour of fingers); Sensation (can the patient feel norm…

31. A patient with dysphagia (difficulty swallowing) is at risk for aspiration. What positioning reduces aspiration risk during feeding?

    • Supine (flat)
    • Trendelenburg (head down)
    • Upright (90 degrees or highest tolerated) during and for 30-60 minutes after meals; thickened liquids if ordered; small bites; slow pace; no talking during swallowing ✓
    • Right side-lying during meals only

    ASPIRATION PRECAUTIONS for dysphagic patients: POSITIONING: HOB at 90 degrees (or highest angle tolerated) during all oral intake and for 30-60 minutes after meals — gravity helps move food toward the stomach; THICKENED LIQUIDS: Per speech-language pathology recommendation, liquids may need to be th…

32. The nurse is preparing to perform venipuncture on a patient. Which action is done LAST in the preparation sequence?

    • Apply the tourniquet
    • Cleanse the site with alcohol and let it dry
    • Don gloves ✓
    • Select the vein site

    VENIPUNCTURE PREPARATION SEQUENCE: (1) Explain the procedure to the patient; (2) Gather supplies; (3) Position the arm; (4) APPLY TOURNIQUET (3-4 inches above proposed site); (5) SELECT the vein (palpate for resilience, direction); (6) RELEASE TOURNIQUET temporarily if taking more than 1 minute; (7)…

33. After removing gloves during patient care, the nurse should perform hand hygiene. What is the correct duration for alcohol-based hand rub?

    • 5 seconds
    • 20-30 seconds (rub until hands are dry — covers all surfaces: palm, back, fingers, fingernails, between fingers) ✓
    • 2 minutes
    • Only required when hands are visibly soiled

    ALCOHOL-BASED HAND RUB TECHNIQUE: Apply adequate amount (follow product instructions) to cover all hand surfaces; rub palm to palm; right palm over left dorsum with interlaced fingers; palm to palm with fingers interlaced; backs of fingers to opposing palms; rotational rubbing of thumbs; rotational …

34. A nurse is preparing an IM injection. The medication is labelled '100 mg/2 mL'. The ordered dose is 75 mg. How many mL should the nurse draw up?

    • 0.75 mL
    • 1.5 mL ✓
    • 2 mL
    • 3 mL

    MEDICATION CALCULATION: Use the formula (Desired ÷ Have) × Volume: Desired: 75 mg. Have: 100 mg. Volume: 2 mL. Calculation: (75 ÷ 100) × 2 = 0.75 × 2 = 1.5 mL. VERIFY WITH DIMENSIONAL ANALYSIS: 75 mg × (2 mL / 100 mg) = 150/100 mL = 1.5 mL. NURSING CHECK: 1.5 mL is within the acceptable range for IM…

35. A nurse is completing a hand-off report for a patient going to surgery. Which framework is most effective for structured verbal reporting?

    • Alphabetical order of problems
    • SBAR — Situation, Background, Assessment, Recommendation — provides a standardised structure that prevents omissions and is understood by all healthcare providers ✓
    • A narrative format chosen by the nurse
    • Only the most recent vital signs

    SBAR (Situation-Background-Assessment-Recommendation) is the Joint Commission-recommended and nationally standardised format for healthcare communication, especially hand-offs. SITUATION: Who the patient is, the immediate issue or reason for the communication ('Mr. Jones, Room 412, 68-year-old, is b…

36. A client with acute confusion (delirium) is trying to get out of bed and has multiple IV lines and a Foley catheter. After attempting re-orientation and distraction, the nurse is considering restraints. What is the correct process?

    • Apply restraints whenever a confused client tries to move
    • Exhaust all least-restrictive alternatives first; obtain a physician's order (required in all states); use the least restrictive restraint appropriate; reassess every 2 hours; provide range of motion, hydration, and skin checks; re-evaluate the need at least every 24 hours ✓
    • Apply soft wrist restraints and check in 8 hours
    • Any nurse can apply any type of restraint without an order

    RESTRAINT USE — REGULATORY REQUIREMENTS: LAST RESORT: Restraints must be used only after less-restrictive alternatives fail (redirection, re-orientation, family presence, positioning, medication review, activity); PHYSICIAN ORDER REQUIRED: No nurse may initiate restraints without an order (except in…

37. A nurse is caring for a client diagnosed with active pulmonary tuberculosis (TB). Which PPE is required when entering the room?

    • Standard surgical mask and gown
    • N95 respirator (or higher) — TB requires AIRBORNE PRECAUTIONS; standard surgical masks do not filter the small droplet nuclei that carry Mycobacterium tuberculosis; the room must be under negative pressure (air flows in, not out); the door must remain closed ✓
    • N95 plus full face shield at all times
    • Only gloves — TB is bloodborne

    TUBERCULOSIS — AIRBORNE PRECAUTIONS: TB spreads via AIRBORNE transmission — tiny droplet nuclei (<5 microns) that remain suspended in air for hours; REQUIRED PPE: N95 respirator (minimum) — must be properly fit-tested for the individual nurse; surgical masks do NOT provide adequate filtration; NEGAT…

38. The LPN receives a telephone order from a physician. What is the correct procedure?

    • Write it down, read it back, and execute it
    • Write the order in the chart, read it back in full to the physician, wait for verbal confirmation that the read-back was correct, and sign the order with your name, credentials, date, time, and 'T.O. (telephone order) Dr. [Name]'; the physician must co-sign within the facility's required timeframe ✓
    • Telephone orders are never permitted for LPNs
    • Execute immediately without documentation

    TELEPHONE/VERBAL ORDER PROCEDURE: SAFETY: High error risk due to misheard words or numbers — standardised read-back prevents most errors; CORRECT PROCESS: Write the order as spoken; read the COMPLETE order back to the prescriber; wait for confirmation ('That is correct' or correction); document as t…

39. A client receiving a blood transfusion reports sudden onset of lower back pain, chills, and feeling flushed 15 minutes into the transfusion. What is the FIRST nursing action?

    • Slow the transfusion rate
    • Stop the transfusion immediately — these symptoms indicate a potential acute haemolytic transfusion reaction (ABO incompatibility), which is life-threatening; stopping the transfusion is the absolute first action; do not remove the IV ✓
    • Call the blood bank first
    • Administer diphenhydramine and continue

    ACUTE HAEMOLYTIC TRANSFUSION REACTION (AHTR): MECHANISM: ABO incompatibility — transfused red cells are destroyed by recipient's antibodies; severe inflammatory cascade; SYMPTOMS: Lower back pain (classic — renal pain from haemoglobinuria); fever/chills; flushing; hypotension; haematuria; LIFE-THREA…

40. Which task can the LPN safely delegate to an unlicensed assistive personnel (UAP)?

    • Administering oral medications
    • Assessing a newly admitted patient
    • Measuring and recording vital signs on a stable client — this is within the UAP scope; it is a data-gathering task for a stable patient, not assessment or judgment requiring nursing licensure ✓
    • Inserting a urinary catheter

    LPN DELEGATION TO UAP: THE DELEGATION FRAMEWORK: The LPN may delegate TASKS (not nursing judgment) to UAPs within the UAP's competency, in the appropriate setting, with proper supervision. APPROPRIATE TO DELEGATE: Vital signs on stable patients; height/weight; routine ADL assistance (bathing, dressi…

41. A nurse is preparing to administer an unfamiliar IV medication. The pharmacy has provided the drug but the nurse is uncertain about the safe administration rate. What is the correct action?

    • Administer it at any rate since it came from the pharmacy
    • Look up the drug in a nursing drug reference or call the pharmacy to confirm the safe infusion rate before administration — never administer an IV medication at an unknown rate; incorrect IV push rates are a leading cause of preventable adverse events ✓
    • Ask a colleague to guess the rate
    • Administer it slowly just to be safe

    SAFE IV MEDICATION ADMINISTRATION: FOUR RIGHTS FOR IV MEDICATIONS: Right drug, right dose, right patient, right time PLUS right rate for IV medications; SAFE IV RATES: Critically important — many IV drugs must be administered over a specified time to prevent adverse effects; too fast = cardiac arrhy…

42. Which activity requires the nurse to perform hand hygiene?

    • Only when gloves are not used
    • Only before invasive procedures
    • Before and after every patient contact, before and after using gloves, after contact with bodily fluids, before a clean/aseptic procedure, after touching patient surroundings even without touching the patient — hand hygiene is required even after removing gloves ✓
    • Only at the start and end of the shift

    WHO 5 MOMENTS OF HAND HYGIENE: (1) BEFORE touching the patient; (2) BEFORE a clean/aseptic procedure; (3) AFTER bodily fluid exposure risk; (4) AFTER touching the patient; (5) AFTER touching patient surroundings; KEY POINTS: Hand hygiene AFTER GLOVE REMOVAL — gloves have micro-tears; hands can be co…

43. The nurse receives a client from surgery. During the hand-off report, which piece of information is MOST critical to verify?

    • The client's room preferences
    • Known allergies — surgical medications, latex, antibiotics, and anaesthetic agents may have been used; if an allergy was not properly documented or communicated, the post-surgical team may unknowingly administer a cross-reactive substance; allergy verification at every hand-off prevents medication errors ✓
    • The client's insurance information
    • The surgeon's contact number

    SBAR HAND-OFF REPORT — PRIORITY ELEMENTS: SITUATION: What procedure was done, current condition; BACKGROUND: Relevant history, reason for surgery; ASSESSMENT: Current vital signs, pain level, assessment findings; RECOMMENDATIONS: Orders, next steps, urgent concerns; CRITICAL TO VERIFY: ALLERGIES (sa…

44. A nurse arrives to administer 8 AM medications and cannot locate a client who was ambulatory and cognitively intact. After a quick room search, the nurse finds the bed empty and the client not in the bathroom. What is the first action?

    • Document that the client is missing and wait for their return
    • Search the immediate unit area, check the visitor lounge and common areas; if not found within a few minutes, notify the charge nurse and implement the facility's elopement/missing patient protocol — this is a safety emergency ✓
    • Call the family before searching further
    • Call the police immediately

    PATIENT ELOPEMENT/MISSING PATIENT: DEFINITION: Elopement = patient leaves a healthcare facility without medical authorisation; RISK ASSESSMENT: Patients at risk: confused/demented; psychiatric patients; patients who have expressed desire to leave; impulsive or cognitively impaired patients; IMMEDIAT…

45. A client is newly diagnosed with MRSA (methicillin-resistant Staphylococcus aureus) in a wound. What precautions are required?

    • Airborne precautions with N95 mask
    • Standard precautions only
    • Contact precautions — gown and gloves upon entering the room; private room preferred; dedicated or single-use equipment (stethoscope, blood pressure cuff); hand hygiene with soap and water or ABHR before and after contact ✓
    • Droplet precautions with surgical mask

    MRSA — CONTACT PRECAUTIONS: TRANSMISSION: Direct contact (touch) with infected wounds, skin, or colonised areas; indirect contact (contaminated surfaces and equipment); MRSA DOES NOT require special respiratory precautions (unless the patient has pneumonia with productive cough — then droplet may be…

46. A client refuses a procedure that their physician believes is necessary. The nurse's role is to:

    • Convince the client to comply
    • Document the refusal, ensure the client understands the risks of refusal (informed refusal), notify the RN and physician, and respect the client's decision — competent adults have the absolute right to refuse any medical treatment ✓
    • Proceed with the procedure anyway
    • Call the client's family to override the refusal

    RIGHT TO REFUSE TREATMENT: LEGAL AND ETHICAL FOUNDATION: Competent adults have an absolute legal and ethical right to refuse any medical treatment or procedure, including life-saving treatments; EXCEPTIONS: Emergency situations where the patient is unconscious or incapacitated and no advance directi…

47. Which assessment finding is most consistent with internal haemorrhage following abdominal surgery?

    • Blood pressure 140/90, HR 68
    • Rising blood pressure with decreasing heart rate
    • Decreasing blood pressure AND increasing heart rate — early signs of haemorrhage: tachycardia as the body compensates for volume loss; narrowing pulse pressure; restlessness and anxiety; then hypotension develops as compensatory mechanisms fail ✓
    • Bradycardia and hypertension

    HAEMORRHAGE RECOGNITION — HAEMODYNAMIC RESPONSE: EARLY COMPENSATED HAEMORRHAGE (Class I-II, up to 1,500 mL blood loss): Heart rate INCREASES (tachycardia) — compensatory sympathetic response; Blood pressure may be maintained or slightly decreased; Anxiety, restlessness; Skin pallor, cool, diaphoreti…

48. A client's medical record contains an advance directive stating 'DNR/DNI — do not resuscitate, do not intubate.' The client is found unresponsive on the unit. What should the nurse do?

    • Begin CPR immediately — advance directives are not binding
    • Check for valid advance directive in the chart; if a valid, current DNR/DNI order is confirmed, provide comfort measures and do not initiate CPR or intubation; notify the RN, physician, and family; document the time, assessment findings, and actions ✓
    • Ignore the DNR since it was written years ago
    • Begin CPR then check the chart

    ADVANCE DIRECTIVE AND DNR ORDERS: LEGAL STATUS: A valid advance directive and physician's do-not-resuscitate order is a LEGAL DOCUMENT that must be honoured; CPR against a DNR order is assault; VALIDITY CHECK: Is the document current? Is it in the medical record? Is there a corresponding physician's…

49. A nurse discovers a medication error — administered the wrong dose of a non-critical medication to a stable patient. The patient appears unaffected. What must the nurse do?

    • Say nothing since no harm occurred
    • Assess the patient for adverse effects; notify the RN and physician about the error; document the medication administered (what was given) objectively in the medical record; complete an incident report (separately from the medical record) — medication errors must be reported regardless of apparent outcome ✓
    • Document the correct dose as ordered and move on
    • Tell only the charge nurse and ask them to handle it

    MEDICATION ERROR REPORTING: MORAL AND LEGAL OBLIGATION: All medication errors must be reported, regardless of apparent harm — this is a patient safety, legal, and regulatory requirement; IMMEDIATE RESPONSE: Assess patient for signs of adverse effects (vital signs, symptoms); report to RN and physici…

50. A nurse is preparing to insert a urinary catheter. Which action is MOST important to prevent catheter-associated urinary tract infection (CAUTI)?

    • Use sterile technique only for the first hour
    • Maintain strict sterile technique throughout the insertion procedure and maintain a closed drainage system — CAUTIs are a major preventable healthcare-associated infection; the majority are preventable with proper insertion technique and maintenance ✓
    • Rinse the catheter with tap water before insertion
    • Change the catheter every 24 hours routinely

    CAUTI PREVENTION BUNDLE: INDICATIONS: Only insert when medically necessary — review daily whether continued catheterisation is needed; INSERTION TECHNIQUE: STERILE: sterile gloves, draping, catheter; cleanse with antiseptic; insert without contamination; CLOSED DRAINAGE: Never disconnect catheter fr…

51. The RN delegates tasks to the LPN and unlicensed assistive personnel (UAP). Which task is appropriate to delegate to the UAP?

    • Administering oral medications
    • Assessing a new admission
    • Measuring and recording vital signs on a stable client — this is within the UAP scope; UAPs perform basic care tasks on stable clients with predictable outcomes ✓
    • Developing the care plan

    DELEGATION TO UAP (Unlicensed Assistive Personnel — CNAs, aides): APPROPRIATE UAP TASKS (the '5 rights of delegation' and stable/predictable rule): Vital signs on STABLE clients; bathing, hygiene, grooming; feeding (non-dysphagic clients); ambulation and positioning; intake/output measurement; speci…

52. A nurse is preparing to administer a medication and notices the prescription reads 'digoxin 0.25 mg PO daily.' The available supply is digoxin 0.125 mg tablets. How many tablets should the nurse give?

    • 1 tablet
    • 2 tablets — 0.25 mg ÷ 0.125 mg per tablet = 2 tablets ✓
    • Half a tablet
    • 4 tablets

    DOSAGE CALCULATION: Desired dose ÷ Available dose per unit = number of units. 0.25 mg (desired) ÷ 0.125 mg (per tablet) = 2 tablets. VERIFICATION: 2 tablets × 0.125 mg = 0.25 mg ✓. MEDICATION SAFETY CHECKS: Always verify the calculation; if a calculation results in an unusual number of tablets (more…

53. A client is admitted with suspected pulmonary tuberculosis (TB). Which type of isolation precaution is required?

    • Contact precautions
    • Droplet precautions
    • Airborne precautions — TB is transmitted via airborne droplet nuclei; requires a negative-pressure room and an N95 respirator (fit-tested) for anyone entering ✓
    • Standard precautions only

    TUBERCULOSIS — AIRBORNE PRECAUTIONS: TB spreads via tiny airborne droplet nuclei that remain suspended in air and travel on air currents. REQUIREMENTS: AIIR (Airborne Infection Isolation Room) — negative pressure relative to the hallway (air flows INTO the room, not out); minimum 6-12 air exchanges …

54. A nurse finds a client on the floor next to the bed. After ensuring the client's immediate safety and assessing for injury, what is the next priority action?

    • Complete an incident report immediately
    • Notify the RN and provider, then document the objective findings in the medical record; the incident report is completed separately and is NOT referenced in the chart ✓
    • Move the client back to bed quickly
    • Call the family first

    POST-FALL PROTOCOL: SEQUENCE: (1) Ensure immediate safety; assess for injury (don't move if spinal injury suspected); assess level of consciousness, vital signs, pain, range of motion, any deformity; (2) Provide necessary care/stabilization; (3) Notify the RN and provider; (4) Document OBJECTIVE fin…

55. What is the correct sequence for DONNING (putting on) personal protective equipment (PPE)?

    • Gloves, gown, mask, goggles
    • Gown, mask/respirator, goggles/face shield, gloves — gown first, gloves last ✓
    • Mask, gloves, gown, goggles
    • Goggles, gloves, gown, mask

    PPE DONNING SEQUENCE (putting ON): (1) GOWN first; (2) MASK or respirator; (3) GOGGLES or face shield; (4) GLOVES last (gloves go over the gown cuffs); MNEMONIC: 'Gown, mask, goggles, gloves'; DOFFING SEQUENCE (taking OFF) — reverse and based on most contaminated first: (1) GLOVES first (most contam…

56. A client with a documented latex allergy is scheduled for a procedure. What is the priority nursing action?

    • Administer an antihistamine before the procedure
    • Ensure a latex-free environment — use latex-free gloves, equipment, and supplies; post latex allergy alerts; schedule the client as the first case of the day when possible (less airborne latex) ✓
    • Keep epinephrine at the bedside but use regular supplies
    • Have the client sign a waiver

    LATEX ALLERGY MANAGEMENT — PREVENTION IS PRIORITY: Create a LATEX-FREE ENVIRONMENT: latex-free gloves (nitrile, vinyl); latex-free equipment (BP cuffs, tourniquets, IV tubing, catheters, syringes); check all supplies for latex content; LATEX ALLERGY ALERTS: Allergy band, chart flag, signage on the d…

57. The charge nurse is making client assignments. Which client is most appropriate to assign to the LPN (rather than the RN)?

    • A newly admitted client requiring an initial assessment
    • A client requiring blood transfusion initiation
    • A stable client with a chronic condition requiring routine medication administration and reinforcement of previously taught education ✓
    • An unstable client requiring frequent reassessment and care plan adjustment

    LPN SCOPE — APPROPRIATE ASSIGNMENTS: LPNs care for STABLE clients with PREDICTABLE outcomes. APPROPRIATE for LPN: Stable clients with chronic, stable conditions; routine medication administration (oral, subcutaneous, IM — IV varies by state); reinforcing teaching the RN already initiated; routine wo…

58. A client tells the LPN, 'I don't want any more treatment. I want to go home.' The client is alert and oriented. What is the nurse's best response?

    • Tell the client they cannot leave because the doctor hasn't discharged them
    • Acknowledge the client's right to refuse treatment, notify the RN and provider, and ensure the client understands the implications of their decision — a competent adult has the right to refuse treatment and to leave (against medical advice if necessary) ✓
    • Call security to prevent the client from leaving
    • Sedate the client until family arrives

    RIGHT TO REFUSE TREATMENT — AUTONOMY: A COMPETENT ADULT has the legal and ethical right to refuse treatment and to leave a healthcare facility, even against medical advice (AMA). NURSING RESPONSE: Acknowledge and respect the client's autonomy; do NOT detain a competent client against their will (tha…

59. A nurse is caring for a client receiving oxygen therapy. Which safety measure is most important in the client's room?

    • Keep the room cool
    • No smoking and no open flames or sources of ignition — oxygen supports combustion; remove all ignition sources, post 'Oxygen in Use' signs, and avoid flammable materials ✓
    • Keep humidity high
    • Dim the lights

    OXYGEN SAFETY — FIRE PREVENTION: Oxygen does not burn itself but VIGOROUSLY SUPPORTS COMBUSTION — fires burn hotter and faster in an oxygen-enriched environment. SAFETY MEASURES: NO SMOKING (post 'Oxygen in Use — No Smoking' signs); no open flames, candles, matches, lighters; avoid electrical equipm…

60. When should a nurse perform hand hygiene according to the WHO 'Five Moments for Hand Hygiene'?

    • Only after touching a client
    • Before touching a client, before a clean/aseptic procedure, after body fluid exposure risk, after touching a client, and after touching the client's surroundings ✓
    • Only when hands are visibly soiled
    • Once at the start of each shift

    WHO FIVE MOMENTS FOR HAND HYGIENE: (1) BEFORE touching a client; (2) BEFORE a clean/aseptic procedure; (3) AFTER body fluid exposure risk; (4) AFTER touching a client; (5) AFTER touching client surroundings (even without touching the client); HAND HYGIENE METHOD: Alcohol-based hand rub for routine d…

61. A nurse is reconciling a client's medications and finds the client is taking warfarin and was just prescribed aspirin by a different provider. What is the priority action?

    • Administer both medications as prescribed
    • Recognize the potential interaction (both increase bleeding risk) and notify the provider before administering — medication reconciliation is a key safety step to catch dangerous interactions and duplications ✓
    • Hold both medications indefinitely
    • Tell the client to choose which one to take

    MEDICATION RECONCILIATION — CATCHING INTERACTIONS: Warfarin (anticoagulant) + aspirin (antiplatelet) = significantly increased bleeding risk; this combination requires provider awareness and may be intentional (some cardiac conditions) or an oversight from separate prescribers. PRIORITY: Recognize t…

62. A nurse witnesses another staff member sharing a client's diagnosis with a visitor who is not authorized to receive that information. What should the nurse do?

    • Ignore it — it's not their responsibility
    • Recognize this as a HIPAA violation (breach of client confidentiality), intervene appropriately, and report it through the proper channels per facility policy ✓
    • Confront the visitor directly and aggressively
    • Post about it on social media to warn others

    HIPAA AND CONFIDENTIALITY: HIPAA (Health Insurance Portability and Accountability Act) protects client health information — disclosing protected health information (PHI) to unauthorized individuals is a violation. NURSE'S RESPONSE: Recognize the breach; intervene to stop the unauthorized disclosure …

63. A nurse is about to administer a medication via a client's nasogastric (NG) tube. What is the priority safety check before administration?

    • Warm the medication
    • Verify NG tube placement (check tube marking, aspirate gastric contents and check pH, confirm proper position) before administering anything through the tube to prevent instillation into the lungs ✓
    • Crush all medications together
    • Flush with 200 mL of water

    NG TUBE MEDICATION SAFETY — VERIFY PLACEMENT: Before instilling ANY medication or feeding through an NG tube, VERIFY PLACEMENT to ensure the tube is in the stomach, not the lungs (a dislodged tube in the airway could cause aspiration of medication/feeding into the lungs — potentially fatal). VERIFIC…

64. A nurse delegates a task to a UAP but remains responsible for the outcome. This principle is best described as:

    • Transfer of liability
    • Accountability — the delegating nurse retains accountability for the delegated task and must ensure it is performed correctly through appropriate supervision; delegation transfers the task, not the accountability ✓
    • Abandonment
    • Substitution

    ACCOUNTABILITY IN DELEGATION: When a nurse delegates a task, the nurse RETAINS ACCOUNTABILITY for ensuring the task is completed correctly and safely. Delegation transfers the RESPONSIBILITY for performing the task, but NOT the ACCOUNTABILITY for the outcome. THE DELEGATING NURSE MUST: Ensure the UA…

65. A client is admitted with a seizure disorder. Which items should be readily available at the bedside for seizure precautions?

    • Padded tongue blade and restraints
    • Suction equipment and oxygen — to maintain a patent airway during and after a seizure; the bed should be in low position with side rails padded ✓
    • A bite block to insert during the seizure
    • Ice packs

    SEIZURE PRECAUTIONS: BEDSIDE EQUIPMENT: Suction equipment (to clear secretions and maintain airway); oxygen (for post-ictal hypoxia); padded side rails; bed in LOW position; DURING A SEIZURE: Protect from injury — do NOT restrain; do NOT put anything in the mouth (the old 'bite block/tongue blade' t…