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Free practice set · 9 questions

9 more free NCLEX-RN® practice questions

Real questions from the same bank the app serves. Pick an answer in your head, then open the rationale to see why the correct option holds and why each other option falls short. No account needed for these.

1. Question 1 of 9 · Ethics, Advocacy & Health Policy

   A 52-year-old Spanish-speaking client admitted for pneumonia is refusing the prescribed IV antibiotics recommended by the health care provider. The client states (in broken English) that he wants to "try natural remedies first" and is worried about injection side effects. His adult daughter is present and speaks fluent English. The client has full decision-making capacity. The nurse recognizes this as a values-based refusal that requires advocacy to ensure the client can make an informed choice aligned with his preferences. Which action should the nurse take to support the client's informed treatment decision?

   1. ATell the client that he should reconsider his preference because the health care provider believes IV antibiotics are the most effective treatment for his condition.
   2. BDocument in the chart that the client is refusing antibiotics and inform the charge nurse that the decision will be communicated to him on the next shift.
   3. CAsk the daughter to interpret the provider's explanation and the potential side effects so she can help her father understand why the IV antibiotics are necessary.
   4. DRequest a qualified medical interpreter to facilitate a conversation between the client, health care provider, and nurse so the client can fully understand the treatment rationale and express his concerns in his preferred language.
   Show the answer and rationale

   Correct answer: D. Request a qualified medical interpreter to facilitate a conversation between the client, health care provider, and nurse so the client can fully understand the treatment rationale and express his concerns in his preferred language.

   Matching the language barrier to clinical communication with a qualified medical interpreter satisfies both advocacy requirements. This ensures the client, who has decision-making capacity, can fully understand the provider's clinical rationale and risks in his preferred language, then express his own values and concerns. The interpreter becomes a bridge to amplify the client's autonomous voice, not substitute for it. The interpretation occurs in real time, enabling informed decision-making now. Using an untrained family member, the daughter, as interpreter for clinical decisions violates the advocacy requirement. Federal and facility language-access policies require qualified medical interpreters for consents and clinical education, even when bilingual family is present. Using the daughter conflates her role as support with her competence in medical terminology and creates potential conflicts of interest. Documenting the refusal without facilitating the client's ability to make an informed choice, or delaying the conversation to the next shift, violates the advocacy requirement by deferring action without addressing the immediate need. This leaves the clinical and values conflict unresolved in the present moment. Advocacy requires timely action when the client cannot fully self-advocate due to language barriers. Redirecting the client toward the nurse-preferred path, "should reconsider", violates the advocacy requirement. The client has already stated his preference; advocacy supports his right to that preference once he has accurate information. Persuading him to override his own values substitutes the nurse's judgment for the client's autonomous voice.

   A. Tell the client that he should reconsider his preference because the health care provider believes IV antibiotics are the most effective treatment for his condition.

   Trying to change the client's preference is an example of the "redirect or talk the client out of their preference" error. It violates the rule that advocacy amplifies the client's voice, not the nurse's judgment. Telling the client he 'should reconsider' based on the provider's preference substitutes the nurse's judgment for the client's autonomous values-based refusal. Advocacy supports the client's right to his preference once he has accurate information.

   B. Document in the chart that the client is refusing antibiotics and inform the charge nurse that the decision will be communicated to him on the next shift.

   Documenting a concern without addressing it is an example of the "document the concern without acting" error. It violates the advocacy rule by postponing timely action. Documenting the refusal alone and deferring the conversation to the next shift leaves the language barrier unaddressed and the client unable to make an informed decision now. Advocacy requires taking action in the moment when the client cannot fully self-advocate.

   C. Ask the daughter to interpret the provider's explanation and the potential side effects so she can help her father understand why the IV antibiotics are necessary.

   Using a family member to interpret clinical information is an example of the "use family member as interpreter for clinical decisions" error. It violates the chain-of-command rule by using an untrained family member instead of a qualified medical interpreter for clinical decisions. Federal language-access requirements and facility policy mandate qualified interpreters for clinical education and consent, even when bilingual family are available. Family interpreters introduce medical terminology gaps and potential conflicts of interest.

   D. Request a qualified medical interpreter to facilitate a conversation between the client, health care provider, and nurse so the client can fully understand the treatment rationale and express his concerns in his preferred language.

   This option satisfies both key rules: it uses the appropriate resource (qualified medical interpreter) matched to the specific trigger (language barrier to clinical communication), and it amplifies the client's voice by enabling him to understand and express his own preferences in his preferred language. The interpreter facilitates informed decision-making without substituting nurse or family judgment.

2. Question 2 of 9 · Nursing Leadership, Delegation & Advocacy

   A newly hired RN works on a surgical unit where a 58-year-old client is 2 days post-open cholecystectomy. The client has stable vital signs, clear lungs, appropriate mental status, and an intact abdominal dressing with minimal serous drainage. Pain is controlled with oral analgesics. The RN is caring for four clients and must prioritize tasks. An experienced AP/UAP on the unit has documented competency in post-operative wound care including dressing changes on this unit. The RN needs to complete several tasks this shift. Which action best demonstrates appropriate delegation?

   1. AAsk the AP/UAP to assess the client's pain level and teach the client which positions promote healing and prevent complications.
   2. BAsk the AP/UAP to perform the scheduled abdominal dressing change and report any abnormal drainage or signs of infection before the RN reviews the wound.
   3. CPerform all dressing changes and assessments personally to ensure client safety and avoid any risk of missed complications.
   4. DAsk the AP/UAP to monitor vital signs and immediately report only if heart rate exceeds 100 bpm, then proceed with other tasks without further checking.
   Show the answer and rationale

   Correct answer: B. Ask the AP/UAP to perform the scheduled abdominal dressing change and report any abnormal drainage or signs of infection before the RN reviews the wound.

   Applying the Five Rights of Delegation supports this plan: the task, a dressing change, is within the AP/UAP's scope and documented competency, which meets the Right Task; the client is stable with a predictable, uncomplicated post-operative course, which meets the Right Circumstances; the AP/UAP has validated competency on this unit, which meets the Right Person; the RN provides clear, specific direction to report abnormal findings, which meets the Right Direction; and the RN retains accountability by reviewing the wound and requiring feedback before independent action by the delegate, which meets the Right Supervision. This delegation is appropriate because post-operative dressing changes on a stable client with predictable wound healing are within assistive personnel scope, and the RN supervises by requiring the delegate to report findings and by independently assessing the wound afterward. Assessing the client's pain and providing post-operative teaching that includes healing promotion and complication prevention require nursing judgment. These functions cannot be delegated to unlicensed personnel and remain RN responsibilities. Delegating the task without adequate follow-up fails the Right Supervision right. Specifying only one threshold, heart rate >100, and then stating "proceed with other tasks without further checking" does not provide effective supervision. The RN should clarify what other abnormal findings to report, including temperature, weakness, chest symptoms, and bleeding, when to report them, and how the RN will verify the AP/UAP's findings, rather than setting a trigger and disappearing. Withholding all delegation is inappropriate. Although the RN must retain assessment and evaluation, delegating a straightforward dressing change on a stable post-operative client to a competent AP/UAP is both safe and necessary to manage workload effectively. Refusing all delegation creates RN fatigue, delays other care, and actually increases risk of errors.

   A. Ask the AP/UAP to assess the client's pain level and teach the client which positions promote healing and prevent complications.

   Violates the "RN retains nursing assessment, evaluation, teaching, and unstable-client care" rule. Pain assessment and client teaching about post-operative healing and complication prevention require nursing judgment and are non-delegable RN functions. Assistive personnel cannot assess pain acuity or teach therapeutic health concepts; these remain with the RN regardless of the AP/UAP's other competencies.

   B. Ask the AP/UAP to perform the scheduled abdominal dressing change and report any abnormal drainage or signs of infection before the RN reviews the wound.

   Satisfies all Five Rights: task is within AP/UAP scope and validated competency (Right Task); client is stable post-op day 2 with uncomplicated wound (Right Circumstances); AP/UAP has documented competency on this unit (Right Person); RN provides specific direction about what abnormal findings to report (Right Direction); RN supervises by requiring delegate feedback and conducting independent wound assessment (Right Supervision). RN retains accountability.

   C. Perform all dressing changes and assessments personally to ensure client safety and avoid any risk of missed complications.

   Violates the principle that appropriate delegation is necessary for safe care. While the RN must retain assessment and evaluation, refusing to delegate routine tasks to competent assistive personnel on a stable client creates RN overload, delays care, and increases error risk. Delegation of wound dressing changes on stable post-operative clients is both safe and appropriate when the delegate is competent.

   D. Ask the AP/UAP to monitor vital signs and immediately report only if heart rate exceeds 100 bpm, then proceed with other tasks without further checking.

   Violates the Right Supervision right of delegation. While the task itself (vital sign monitoring) is delegable, the RN provides inadequate supervision by naming only one threshold (HR >100), failing to specify other abnormal findings to report (fever, hypotension, altered mental status), and stating the RN will not check findings afterward. Effective supervision requires clear escalation criteria and RN verification of delegate actions.

3. Question 3 of 9 · Heart Failure & Cardiac Output

   A 68-year-old client admitted 2 days ago with acute decompensated heart failure is on diuretics and a beta-blocker. Vital signs 4 hours ago were: HR 88 bpm, BP 118/72 mmHg, RR 18/min, SpO2 96% on 2 L oxygen, temperature 36.8°C. Current vital signs are: HR 105 bpm, BP 102/68 mmHg, RR 20/min, SpO2 94% on 2 L oxygen, temperature 36.9°C. The client is alert and oriented, skin is warm and dry, no acute respiratory distress noted. Lung sounds show fine crackles at the bases bilaterally. Which action should the nurse take next?

   1. ANotify the provider immediately that the systolic BP has dropped below 110 mmHg and administer an ordered PRN fluid bolus without rechecking.
   2. BReassess vital signs in 5 minutes, document the trend, and notify the provider with SBAR including the 4-hour decline pattern and current clinical status.
   3. CCall for rapid response team activation immediately because the client has persistent basilar crackles indicating worsening pulmonary edema.
   4. DDocument the vital signs and continue scheduled monitoring every 4 hours because the current BP of 102/68 mmHg remains above 90 mmHg systolic.
   Show the answer and rationale

   Correct answer: B. Reassess vital signs in 5 minutes, document the trend, and notify the provider with SBAR including the 4-hour decline pattern and current clinical status.

   This client's vital-sign trend over 4 hours signals evolving hemodynamic instability in the context of acute heart failure: heart rate has climbed from 88 to 105 bpm, systolic BP has fallen from 118 to 102 mmHg (a 16 mmHg decline), and respiratory rate has increased from 18 to 20/min. While the current BP of 102/68 remains above the critical threshold of 90 mmHg systolic and SpO2 is acceptable, the downward trend in BP paired with the upward trend in HR and RR suggests compensatory physiology, meaning the client is beginning to decompensate. The principle that trend supersedes any single isolated value is essential here: a 16 mmHg drop over 4 hours in a heart-failure client on diuretics warrants urgent reassessment and provider notification, even though the latest reading is not yet critical. This action follows three key principles: (1) the nurse recognizes the constellation of abnormal changes and their relationship to the client's condition, (2) treats the downward BP trend and upward HR/RR trend as the critical signal, not the single latest value, and (3) performs focused reassessment (confirming LOC, perfusion, work of breathing, and device) before escalating with complete SBAR data including the trend over time. Acting on a single BP reading (102 mmHg) without context and administering fluid without a provider order violates the assess-before-escalating rule. Dismissing the 16 mmHg decline and the climbing HR because the BP is 'still above 90' misses the trend entirely and violates the rule that trend beats isolated value. Focusing on the basilar crackles (an expected and stable finding in acute decompensated heart failure) rather than addressing the vital-sign trend that signals acute deterioration fails to prioritize the most urgent change.

   A. Notify the provider immediately that the systolic BP has dropped below 110 mmHg and administer an ordered PRN fluid bolus without rechecking.

   This option violates the assess-before-escalating rule by notifying the provider based on a single reading (BP 102 mmHg) without reassessment or trend correlation. It also violates scope by administering a fluid bolus 'without rechecking,' treating an isolated value as definitive and acting outside the standard protocol of gathering complete assessment data first.

   B. Reassess vital signs in 5 minutes, document the trend, and notify the provider with SBAR including the 4-hour decline pattern and current clinical status.

   This option correctly recognizes the 4-hour downward BP trend (118→102 mmHg) and upward HR/RR trend as a concerning pattern in heart-failure context, satisfying the rule that trend supersedes isolated value. It mandates focused reassessment (confirmed in stem: alert, warm, dry, no distress) before escalation, meeting the assess-before-escalating rule. The SBAR notification includes both abnormal values and clinical trend, fulfilling complete provider communication.

   C. Call for rapid response team activation immediately because the client has persistent basilar crackles indicating worsening pulmonary edema.

   This option focuses on basilar crackles, an expected and stable finding in acute decompensated heart failure, rather than addressing the vital-sign trend that signals acute hemodynamic shift. It escalates to rapid response without reassessment, violating the assess-before-escalating rule and failing to prioritize the most clinically urgent change, the downward BP and upward HR/RR trends, over a static pulmonary finding.

   D. Document the vital signs and continue scheduled monitoring every 4 hours because the current BP of 102/68 mmHg remains above 90 mmHg systolic.

   This option violates the core rule that trend beats isolated value. Although BP 102/68 is above the critical threshold of 90 mmHg systolic, the 4-hour downward trend in BP plus upward trends in HR and RR signal deterioration. Delaying until the next 4-hour check ignores the rule to act on concerning trends even when the latest reading is technically 'in range', wrong timing for an evolving change.

4. Question 4 of 9 · Ethics, Advocacy & Health Policy

   A 72-year-old client admitted for hypertension management states, "I will not take any blood pressure medication that makes me tired. My work as a volunteer at the community center is too important to me." The health care provider has written an order for a beta-blocker known to cause fatigue. The client has full decision-making capacity. The nursing staff have access to a charge nurse, social work, clinical pharmacist, and the electronic health record system. Which action should the nurse take in response to the client's medication concern?

   1. ADocument the client's concern in the chart and continue the prescribed beta-blocker for the night shift to reassess in the morning.
   2. BRefer the situation to the hospital ethics committee for review of the medication order disagreement.
   3. CSuggest to the client that volunteer work may need to be postponed temporarily while adjusting to the medication.
   4. DContact the charge nurse and request a meeting with the provider to discuss alternative antihypertensive agents that align with the client's lifestyle needs.
   Show the answer and rationale

   Correct answer: D. Contact the charge nurse and request a meeting with the provider to discuss alternative antihypertensive agents that align with the client's lifestyle needs.

   The client has clearly communicated a preference tied to his values, maintaining volunteer work that gives his life meaning, and has identified a side effect that he considers unacceptable. The advocacy trigger here is a medication order that conflicts with the client's stated preference and quality-of-life goals. Because the client has decision-making capacity, the nurse's role is to amplify his voice by ensuring his concerns are heard and explored by the provider who can prescribe an alternative. Contacting the charge nurse to facilitate a discussion with the provider is the appropriate first step: it uses the lowest-level resource (unit-based coordination) to address a clinical disagreement that does not require ethics, social work, or pharmacy consultation alone. The charge nurse can help ensure the provider understands the client's non-negotiable preference and explore alternatives (e.g., ACE inhibitors, calcium channel blockers, diuretics) that are less likely to cause fatigue. This action respects the client's autonomy and positions the nurse as his advocate within the existing care team. Option A defers action and places the unmet need in the chart without immediately supporting the client's stated boundary, leaving him to receive a medication he has explicitly refused. Option C dismisses the client's preference by counseling him to change his life plan rather than supporting him in communicating his needs to the provider; this substitutes the nurse's judgment for the client's autonomous choice. Option B escalates prematurely to ethics, a routine medication-alternative disagreement does not constitute an ethical dilemma; it is a clinical communication and prescribing decision that the charge nurse and provider can resolve directly.

   A. Document the client's concern in the chart and continue the prescribed beta-blocker for the night shift to reassess in the morning.

   Violates the "advocate amplifies the client's voice, does not substitute" rule and the timing requirement. Documenting without acting defers the advocacy response and allows a medication the client has refused to be administered, leaving his stated boundary unaddressed. Advocacy requires immediate action when the client cannot self-advocate.

   B. Refer the situation to the hospital ethics committee for review of the medication order disagreement.

   Violates the "advocacy uses the appropriate resource and chain of command" rule. This option escalates a routine medication-alternative disagreement to the ethics committee, which is reserved for genuine ethical conflicts (e.g., conflicts over resuscitation status, religious refusal of lifesaving treatment, or competing autonomy issues). A prescriber-client preference mismatch is resolved via direct communication and charge nurse coordination, not ethics.

   C. Suggest to the client that volunteer work may need to be postponed temporarily while adjusting to the medication.

   Violates the "advocate amplifies the client's voice, does not substitute" rule. This option redirects the client away from his stated preference instead of supporting it. The nurse is counseling the client to change his priority (volunteer work) rather than helping him express that priority to the provider, substituting the nurse's judgment for the client's autonomous choice.

   D. Contact the charge nurse and request a meeting with the provider to discuss alternative antihypertensive agents that align with the client's lifestyle needs.

   Correct. This action amplifies the client's voice by using the appropriate chain of command (charge nurse) to facilitate dialogue between client preference and provider ordering. It matches the trigger, a medication order at odds with stated preference, with the right resource for resolution at the unit level. The nurse advocates without substituting judgment.

5. Question 5 of 9 · Ethics, Advocacy & Health Policy

   A 48-year-old client hospitalized with pneumonia speaks limited English. The health care provider orders a chest X-ray and explains the procedure verbally. When the nurse checks in 20 minutes later, the client asks in broken English, "Why they want picture of my lung? I afraid of radiation." The client's daughter, who is bilingual, is present at the bedside and offers to explain the procedure to her mother. The nurse recognizes the client needs clear information in her preferred language before consenting to the imaging.

   1. ADocument the client's concerns about radiation in the medical record and notify the next shift nurse to address the language barrier.
   2. BRequest a qualified medical interpreter to explain the X-ray procedure, indications, and risks so the client can make an informed decision in her own language.
   3. CAsk the daughter to explain the procedure to her mother now since she is bilingual and available at the bedside.
   4. DCounsel the client that modern chest X-rays use minimal radiation and are safer than she thinks to reduce her anxiety about the procedure.
   Show the answer and rationale

   Correct answer: B. Request a qualified medical interpreter to explain the X-ray procedure, indications, and risks so the client can make an informed decision in her own language.

   The client's language barrier is the trigger for advocacy. She has stated fear and lack of understanding about the proposed diagnostic procedure, an unmet need to receive information in her preferred language. The correct action is to request a qualified medical interpreter. This action amplifies the client's own voice by ensuring she receives accurate, unbiased information directly in her language so she can express her autonomous informed consent or refusal. Federal language-access law and facility policy require qualified medical interpreters for clinical decision-making communication, not family members who may have emotional stakes in the decision or lack clinical training. Using the daughter violates this legal and ethical standard and risks miscommunication. Documenting the concern without taking immediate action defers the client's need to the next shift, failing the duty to advocate when the client cannot self-advocate now. Counseling the client toward acceptance of the X-ray substitutes the nurse's judgment about acceptable risk for the client's own expression of her fears; it redirects rather than amplifies her voice. The appropriate resource, a qualified medical interpreter, matches the specific trigger (language barrier) and the lowest level of intervention needed to resolve it.

   A. Document the client's concerns about radiation in the medical record and notify the next shift nurse to address the language barrier.

   Documenting without taking immediate action violates the duty to advocate timely when the client cannot self-advocate. The language barrier and consent need are urgent and require action now, not deferral to the next shift.

   B. Request a qualified medical interpreter to explain the X-ray procedure, indications, and risks so the client can make an informed decision in her own language.

   Correct: Requesting a qualified medical interpreter amplifies the client's autonomous voice by ensuring she receives unbiased clinical information in her preferred language. This action matches the language-barrier trigger and respects federal and facility language-access requirements, allowing informed consent.

   C. Ask the daughter to explain the procedure to her mother now since she is bilingual and available at the bedside.

   Using a family member instead of a qualified medical interpreter violates language-access law and facility policy for clinical decisions. The daughter may have emotional investment in the outcome and lacks clinical training, risking miscommunication and undermining informed consent.

   D. Counsel the client that modern chest X-rays use minimal radiation and are safer than she thinks to reduce her anxiety about the procedure.

   Counseling the client toward acceptance substitutes the nurse's judgment about acceptable risk for the client's autonomous expression of her concerns. Advocacy supports the client's voice, not persuades her to adopt the nurse-preferred path.

6. Question 6 of 9 · Ethics, Advocacy & Health Policy

   A 68-year-old client admitted to the post-acute care unit following hip surgery requires written discharge instructions and education about wound care. The client speaks Spanish as a primary language and has limited English proficiency. The client's adult daughter is present and offers to interpret the discharge instructions and explain the dressing-change procedure. The unit has access to a qualified medical interpreter through the facility's language-access service. The client asks the nurse, "Will someone explain this in Spanish so I understand how to care for myself at home?"

   1. AEncourage the client to try to understand the instructions in English with the daughter's help before requesting an interpreter.
   2. BAccept the daughter's offer to interpret the discharge instructions and wound-care education.
   3. CDocument the client's language barrier and discharge-education need in the chart for the next shift to follow up.
   4. DArrange for the qualified medical interpreter to provide discharge education and wound-care instructions in Spanish.
   Show the answer and rationale

   Correct answer: D. Arrange for the qualified medical interpreter to provide discharge education and wound-care instructions in Spanish.

   The client's clear request for Spanish-language discharge education, combined with documented limited English proficiency, is a direct advocacy trigger: a language barrier to understanding critical self-care information. Advocacy requires amplifying the client's autonomous voice by matching the barrier to the appropriate resource. Federal language-access law and standard nursing practice mandate qualified medical interpreters for clinical decisions, discharge instructions, and informed consent, not family members, to ensure accuracy, confidentiality, and the client's ability to provide fully informed consent to the discharge plan. Arranging the qualified interpreter directly addresses the client's stated need, removes the barrier to understanding, and honors the client's autonomous decision-making at discharge. Using a family member instead of a qualified interpreter violates the advocacy rule. Although the daughter means well, family interpretation carries risks of information distortion, role confusion (interpreter vs. advocate), and breach of confidentiality, and violates facility policy and language-access standards. Encouraging the client to try to understand English instructions redirects her request despite her stated preference and limited proficiency; this substitutes the nurse's judgment (that she "try" English first) for the client's autonomous request for Spanish explanation. Documenting the need for the next shift defers action without addressing the immediate need; advocacy requires timely action when the client cannot access information due to a language barrier. Arranging the qualified interpreter is the lowest-level, appropriate resource that directly resolves the trigger.

   A. Encourage the client to try to understand the instructions in English with the daughter's help before requesting an interpreter.

   Violates the "redirect or talk the client out of their preference" error pattern. This option attempts to talk the client away from her explicit preference for Spanish-language education. It substitutes the nurse's judgment ('try English first') for the client's autonomous request, undermining her voice rather than supporting it.

   B. Accept the daughter's offer to interpret the discharge instructions and wound-care education.

   Violates the "use family member as interpreter for clinical decisions" error pattern. Using a family member as interpreter instead of a qualified medical interpreter breaches language-access standards and clinical safety. Family interpretation risks information errors, role confusion, and confidentiality loss, and fails to reliably support the client's informed consent to the discharge plan.

   C. Document the client's language barrier and discharge-education need in the chart for the next shift to follow up.

   Violates the "document the concern without acting" error pattern. Documenting the need without acting leaves the client unable to understand critical discharge instructions at the moment of greatest need. Advocacy requires timely action to resolve the language barrier now, not deferral to the next shift.

   D. Arrange for the qualified medical interpreter to provide discharge education and wound-care instructions in Spanish.

   Correct. This action directly addresses the language barrier by arranging a qualified medical interpreter, the appropriate resource for clinical communication, discharge education, and informed decision-making. It amplifies the client's voice by enabling her to understand her care and self-advocate at home.

7. Question 7 of 9 · Nursing Leadership, Delegation & Advocacy

   An RN is assigned to four clients on a medical–surgical unit. One client, admitted yesterday with a chronic urinary tract infection, is hemodynamically stable with consistent vital signs and a clear care plan for hydration and antibiotic administration. The RN has verified that the unit's certified nursing assistant (CNA) has been trained and validated on bedside care and assistance with activities of daily living on this unit. The RN plans to delegate hygiene assistance and positioning to the CNA. Which nursing action best demonstrates the Right Supervision component of delegation?

   1. ADelegate the client's initial pain assessment and fluid status evaluation to the CNA along with the hygiene assistance.
   2. BAssign the task without further discussion, trusting that the CNA will communicate any concerns.
   3. CTell the CNA to report back on the client's skin condition and fluid intake, and check the client's hygiene yourself after the CNA finishes.
   4. DPerform all personal hygiene and positioning tasks yourself to ensure the client receives the best possible care.
   Show the answer and rationale

   Correct answer: C. Tell the CNA to report back on the client's skin condition and fluid intake, and check the client's hygiene yourself after the CNA finishes.

   The client is stable with predictable needs, and the CNA’s competency for routine care has been validated, so hygiene and positioning are appropriate to delegate. The RN’s responsibility continues after assignment: provide clear expectations for information to report, follow up on the care, and evaluate the client’s response. This supervision allows the RN to recognize concerns and intervene while remaining accountable for the nursing care provided.

   A. Delegate the client's initial pain assessment and fluid status evaluation to the CNA along with the hygiene assistance.

   This option violates the Right Task and the RN's non-delegable assessment function. Nursing assessments (pain, fluid status) requiring clinical judgment are non-delegable; the RN must retain evaluation and assessment of outcomes. Only routine hygiene and positioning are appropriate to delegate.

   B. Assign the task without further discussion, trusting that the CNA will communicate any concerns.

   This option violates the Right Supervision/Evaluation right. Delegating without specifying what observations to report or how the RN will verify task completion leaves the client without explicit RN oversight and removes the accountability mechanism required for safe delegation.

   C. Tell the CNA to report back on the client's skin condition and fluid intake, and check the client's hygiene yourself after the CNA finishes.

   This option satisfies the Right Supervision by establishing clear feedback expectations (report on skin condition and fluid intake) and a verification plan (RN checks hygiene afterward). The RN remains accountable, can identify complications early, and ensures safe delegation of a stable client's routine care.

   D. Perform all personal hygiene and positioning tasks yourself to ensure the client receives the best possible care.

   This option reflects refusal to delegate any task. Over-centralizing care overloads the RN and fragments team-based care. For stable clients with predictable outcomes, appropriate delegation of routine tasks (within scope and competency) is a hallmark of safe, efficient care, not a safety risk.

8. Question 8 of 9 · Nursing Leadership, Delegation & Advocacy

   A nurse is reviewing the care plan for a 68-year-old client with chronic obstructive pulmonary disease (COPD) admitted 3 days ago with an acute exacerbation. Assessment data: respiratory rate 28 breaths/min, SpO2 88% on 2L nasal cannula, pursed-lip breathing observed, barrel chest noted. The initial outcome was "SpO2 ≥92% on room air by POD2." The client is now on POD3 and SpO2 remains 88% despite oxygen therapy and current interventions (bronchodilators, corticosteroids, chest physiotherapy). The client reports persistent shortness of breath and increased fatigue. What action should the nurse take at this time?

   1. AUpdate the care plan to include a new outcome: 'Client will feel better and breathe easier over the next few days.'
   2. BEvaluate the unmet outcome, revise the oxygen delivery method to maintain SpO2 ≥92%, and update the timeline to POD5, documenting the rationale for changes.
   3. CAdd anxiety-reduction interventions and relaxation techniques to address the client's fatigue and worry about breathing.
   4. DContinue the current interventions unchanged, as the client is still receiving prescribed medications and therapies as ordered.
   Show the answer and rationale

   Correct answer: B. Evaluate the unmet outcome, revise the oxygen delivery method to maintain SpO2 ≥92%, and update the timeline to POD5, documenting the rationale for changes.

   The client presents with an active, unstable breathing problem, acute exacerbation of COPD with SpO2 88% on oxygen, tachypnea (RR 28), and persistent dyspnea on POD3. The original SMART outcome (SpO2 ≥92% on room air by POD2) has been unmet by the target date and the client's status has not improved. According to the nursing process and key rules for care plan management, when a measurable outcome is unmet by its target date, the nurse must evaluate the effectiveness of current interventions, revise the plan (e.g., escalate oxygen delivery, intensify airway clearance, or consider additional medical consultation), and update the outcome target (e.g., extend timeline or adjust the threshold). This action honors both the SMART-outcome rule and the revision-when-unmet rule. Option D violates the revision-when-unmet rule: continuing unchanged interventions after the outcome has not been met is unsafe and ignores the assessment data (persistently low SpO2). Option A violates the SMART-outcome rule: "feel better and breathe easier" are not specific, measurable, or time-bound; evaluation cannot occur without concrete criteria. Option C misidentifies the priority problem, anxiety and fatigue are lower-acuity concerns compared to the acute, life-threatening breathing problem (ABCs take precedence). Adding interventions without first evaluating and revising the primary plan also skips the evaluation step.

   A. Update the care plan to include a new outcome: 'Client will feel better and breathe easier over the next few days.'

   This option violates the SMART-outcome rule. Outcomes like 'feel better' and 'breathe easier' lack specificity, measurability, and time-bound criteria, making evaluation impossible. A plan cannot be evaluated or revised if goals are vague.

   B. Evaluate the unmet outcome, revise the oxygen delivery method to maintain SpO2 ≥92%, and update the timeline to POD5, documenting the rationale for changes.

   This option applies both key rules: it recognizes that SpO2 ≥92% was unmet by POD2 (assesses data against outcome), evaluates the current oxygen and intervention effectiveness, revises the plan by escalating oxygen delivery to meet the outcome, and updates the timeline, all hallmarks of SMART-outcome-driven, evaluation-driven care plan revision. The action directly addresses the assessment finding (SpO2 88%) and the priority problem (acute gas exchange impairment).

   C. Add anxiety-reduction interventions and relaxation techniques to address the client's fatigue and worry about breathing.

   This option violates both priority and process rules. The client has an acute, unstable airway/breathing problem (SpO2 88%, RR 28); anxiety/fatigue are secondary concerns (per ABCs). Adding interventions without first evaluating and revising the primary gas-exchange plan skips the evaluation step and addresses a lower-priority problem.

   D. Continue the current interventions unchanged, as the client is still receiving prescribed medications and therapies as ordered.

   This option violates the revision-when-unmet rule. The client has not met the original outcome (SpO2 88% ≠ ≥92%) by the target date, yet the option continues current interventions without change. Proceeding unchanged ignores the assessment data and risks perpetuating ineffective care.

9. Question 9 of 9 · Nursing Leadership, Delegation & Advocacy

   A client with COPD is admitted with a nursing problem of impaired gas exchange. Initial vitals: respiratory rate 28 breaths/min, SpO2 88% on room air, BP 140/88 mmHg, HR 102 bpm. A care plan was initiated with the measurable outcome "SpO2 ≥92% on room air within 24 hours" and interventions including oxygen therapy, positioning, and pursed-lip breathing education. After 18 hours, reassessment shows: RR 24, SpO2 90% on room air, HR 98 bpm. The client reports less dyspnea but has not yet met the target. Which action should the nurse take now?

   1. AUpdate the plan to focus on teaching the client about COPD self-management and wellness to help the client feel more confident managing the disease.
   2. BAdd new interventions such as incentive spirometry and consultation with respiratory therapy without first reviewing whether the current oxygen and positioning strategies are effective.
   3. CContinue the existing care plan unchanged because the outcome deadline has not yet passed; reassess only if SpO2 remains below 90% tomorrow.
   4. DEvaluate which interventions are partially working, continue current oxygen and positioning strategies, and revise the outcome to SpO2 ≥88% or adjust the time frame based on the client's response.
   Show the answer and rationale

   Correct answer: D. Evaluate which interventions are partially working, continue current oxygen and positioning strategies, and revise the outcome to SpO2 ≥88% or adjust the time frame based on the client's response.

   A nursing plan must be revised when the outcome is unmet or the client's status changes. At 18 hours, the client's SpO2 (90%) has improved from 88% but has not yet reached the 92% target. The assessment shows progress, the respiratory rate is declining, and dyspnea is improving, indicating partial effectiveness of the current interventions. The nurse must evaluate this response, recognize what is working, and either adjust the time frame, acknowledging slower progression, or revise the outcome criteria by setting a more realistic intermediate target while continuing interventions that show benefit. This fulfills the evaluation and update steps of the nursing process. Continuing the plan unchanged violates the revision rule because progress is unmet; it waits passively for the deadline rather than actively evaluating and adjusting based on current data. Shifting to low-acuity education about self-management violates the priority rule because the client has an active, unstable gas exchange problem requiring immediate physiologic support. Adding new interventions without first evaluating whether the current oxygen and positioning strategies are contributing to the improving trend violates the process rule and skips the critical evaluation step before revision.

   A. Update the plan to focus on teaching the client about COPD self-management and wellness to help the client feel more confident managing the disease.

   Choosing to "plan around a low-priority problem when an unstable problem is active" is an error in care planning. Adding a wellness and confidence-building focus on COPD self-management is a low-priority problem when the client has an active, unresolved gas exchange deficit (SpO2 still 90%, RR 24). Acute physiologic needs (ABCs/Maslow) must be stabilized before educational and psychosocial goals.

   B. Add new interventions such as incentive spirometry and consultation with respiratory therapy without first reviewing whether the current oxygen and positioning strategies are effective.

   Choosing to "update the plan without evaluating prior interventions" is an error in care planning. Adding new interventions (incentive spirometry, respiratory consult) without first evaluating whether the current oxygen and positioning are contributing to the improvement violates the nursing process. Evaluation of current intervention effectiveness must precede revision and addition of new strategies.

   C. Continue the existing care plan unchanged because the outcome deadline has not yet passed; reassess only if SpO2 remains below 90% tomorrow.

   Choosing to "continue the existing plan when the outcome is unmet" is an error in care planning. Waiting passively until the 24-hour deadline without evaluating the client's progress violates the "revise the plan when the outcome is unmet or the client status changes" rule. The outcome has not been met by the target date; the nursing process requires evaluation and revision at this point, not passive continuation.

   D. Evaluate which interventions are partially working, continue current oxygen and positioning strategies, and revise the outcome to SpO2 ≥88% or adjust the time frame based on the client's response.

   Correct. This action applies the "revise the plan when the outcome is unmet or the client status changes" rule by evaluating the client's 18-hour response (SpO2 improving from 88% to 90%, RR declining, dyspnea lessening), recognizing partial effectiveness of current interventions, and revising either the time frame or outcome criteria based on this data. It honors the SMART outcome principle by keeping the goal measurable and time-bound while adjusting expectations to the client's actual response.