Question

A nurse is working with an assistive personnel (AP) who refuses a client assignment. When resolving this conflict, which of the following comments is appropriate for the nurse to make?

Answer 1

Correct Answers:

"I need to talk to you about the unit policies regarding client assignments."

Rationale :

🟦 This statement focuses on policy, not personal feelings, which supports professional conflict resolution.

🟦 It keeps the discussion objective and clear, avoiding blame or emotional escalation.

🟦 Addressing policies reinforces the AP’s responsibility within the scope of their role.

🟦 It allows the nurse to clarify expectations and identify any misunderstandings.

🟦 This approach aligns with leadership principles by promoting respectful communication.

I have to let human resources know

🟦 This escalates the issue prematurely.

🟦 Conflict should be addressed directly first before involving HR.

I feel that you are being inconsiderate

🟦 Uses blaming language that increases defensiveness.

🟦 Ineffective in resolving professional disagreements.

You always get your choice

🟦 Uses absolute language (“always”) and is accusatory.

🟦 Not appropriate for leadership communication.

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Answer 2

Correct Answers:

Obtain the client's vital signs.

Rationale :

🟩 The nurse must first assess the client to determine injury or instability.

🟩 Vital signs give immediate data about circulatory or neurological compromise after a fall.

🟩 Assessment always precedes intervention to ensure patient safety.

🟩 Checking vitals helps identify complications such as hypotension, bradycardia, or bleeding.

🟩 This aligns with the nursing process: assess first.

Inform the family member

🟩 Family notification is not priority before assessment.

🟩 Client safety comes first.

Notify the provider

🟩 The provider needs information after assessment, not before.

🟩 Calls must include objective findings.

Assist the client back to bed

🟩 Unsafe until injuries are ruled out.

🟩 Moving too soon may worsen possible fractures or bleeding.

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Answer 3

Correct Answers:

A client who is 4 hr postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr

Rationale :

🟨 Urine output <30 mL/hr suggests impaired perfusion or acute kidney injury.

🟨 This is a postoperative complication requiring immediate intervention.

🟨 Low output can indicate hypovolemia, hemorrhage, or renal failure.

🟨 Early recognition prevents progression to shock.

🟨 This is the only finding that reflects actual physiological instability.

Blood transfusion BP 138/76

🟨 BP is stable.

🟨 No sign of transfusion reaction.

Dementia and oriented to person

🟨 Baseline for many dementia patients.

🟨 Not an acute change.

Traction pain 4/10

🟨 Mild pain is expected.

🟨 Stable finding, not priority.

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Answer 4

Correct Answers:

"The final step in delegation is evaluation of the outcomes."

Rationale :

🟪 The nurse must evaluate whether the delegated task achieved desired outcomes.

🟪 Evaluation maintains accountability, which the nurse never relinquishes.

🟪 It ensures the task was performed safely and effectively.

🟪 Outcome review identifies opportunities for feedback or correction.

🟪 This aligns with the 5 rights of delegation.

Nurse gives up accountability

🟪 The nurse maintains full accountability for all delegated care.

🟪 Incorrect principle.

A delegated task does not require predictable outcomes

🟪 Delegation requires predictable outcomes for safety.

🟪 Unpredictable results must remain with the RN.

AP should document the client’s outcome

🟪 The AP documents task completion, not outcome evaluation.

🟪 Evaluation is the nurse’s responsibility.

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Answer 5

Correct Answers:

"I can arrange for a male AP to do your personal hygiene care."

Rationale :

🟫 This response respects the client’s cultural, religious, or personal preferences.

🟫 It avoids confrontation and maintains therapeutic rapport.

🟫 Offering accommodation supports client-centered care.

🟫 It demonstrates respect for modesty and privacy needs.

🟫 The nurse provides a solution rather than questioning or dismissing the concern.

Notify the charge nurse

🟫 Escalation is unnecessary before attempting reasonable accommodation.

🟫 The nurse can address the request directly.

AP is very capable

🟫 This dismisses the client's comfort.

🟫 Not patient-centered.

Why don’t you want

🟫 Confrontational and intrusive.

🟫 Not therapeutic communication.

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Answer 6

Correct Answers:

List of current medications

Rationale :

🟦 A complete list of current medications is essential for continuity of care during transfer to rehabilitation.

🟦 Medication reconciliation helps prevent omissions, duplications, or medication errors at the receiving facility.

🟦 It ensures the rehabilitation team maintains correct dosing of anticoagulants, pain medications, and chronic therapies, which are critical after a hip replacement.

🟦 Knowing all medications allows the next team to safely modify treatment based on labs, mobility status, and comorbidities.

🟦 This information is a required element of safe hand-off communication during facility transfers.

Vital signs for the past 72 hr

🟦 Only current or recent vital signs are generally needed; 72-hour history is unnecessary and excessive.

🟦 It does not improve safety as much as essential clinical information like medications.

Last bath given

🟦 Bath time is not clinically relevant for transfer decisions.

🟦 Rehabilitation facilities focus on medical stability and treatment needs, not hygiene timing.

Admission paperwork

🟦 Admission documentation stays in the original facility; it is not part of required handover information.

🟦 Transfer requires current clinical data, not administrative intake forms.

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Answer 7

Correct Answers:

Focus on providing care that prevents life-threatening emergencies.

Rationale :

🟩 During a disaster, nurses prioritize triage and life-saving interventions, because resources and time are limited.

🟩 This action aligns with disaster protocols that classify clients based on the severity of their condition.

🟩 The goal is to stabilize individuals at greatest risk of death or rapid deterioration.

🟩 Nurses focus on airway, breathing, circulation, and controlling bleeding to prevent avoidable fatalities.

🟩 This responsibility reflects the nurse’s central role in disaster response and emergency management.

Reinforce discharge teaching to clients

🟩 Teaching is not a priority during disaster response and diverts attention from life-saving needs.

🟩 Education can occur later when the emergency phase is resolved.

Instruct the AP to focus on clients’ ADLs

🟩 ADLs are low-priority during disaster conditions.

🟩 Resources must be directed toward clients with life-threatening conditions.

Stock additional unit supplies

🟩 Supply preparation is part of disaster planning, not the nurse’s priority during active disasterresponse.

🟩 The immediate role is triage and clinical care, not logistics.

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Answer 8

Correct Answers:

Observe a confused surgical client who has multiple tubes.

Rationale :

🟦 A confused surgical client with multiple tubes (e.g., drains, IV lines, catheters) requires continuous clinical assessment, which is outside the AP’s scope.

🟦 Observation in this case is not simple “sitting,” but involves monitoring for tube dislodgement, bleeding, respiratory changes, and altered mental status, all requiring nursing judgment.

🟦 Only licensed nurses can safely evaluate changes in behavior or deterioration in clients with postoperative complications.

🟦 Delegating this increases risk of accidental removal of lines or drains, which can be life-threatening.

🟦 This client requires professional monitoring because confusion places them in the high-risk category for injury.

Assist a client to eat who has difficulty seeing the foods on the tray

🟦 This is an appropriate AP task because it involves basic feeding assistance, not clinical assessment.

🟦 Visual impairment does not require licensed nursing judgment.

Provide postmortem care for a client who has died

🟦 APs are routinely trained to perform postmortem care under nurse direction.

🟦 This task is standardized, predictable, and within AP scope.

Deliver a client's urine specimen to the laboratory

🟦 Transporting specimens is a non-clinical task appropriate for APs.

🟦 This task does not require assessment or decision-making

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Answer 9

Correct Answers:

Whether the task is within the AP's job description

Rationale :

🟦 Before delegating any activity, the nurse must confirm that the task is within the AP’s job description, scope of practice, and facility policy.

🟦 Delegating tasks outside this scope places the client at risk and violates legal and professional standards.

🟦 Ensuring scope alignment allows the nurse to delegate safely while retaining accountability for outcomes.

🟦 This determination supports proper delegation following the Five Rights of Delegation, specifically the Right Task.

🟦 Knowing what APs are permitted to do prevents unsafe assignments and ensures appropriate use of team members.

The AP's ability to prioritize

🟦 APs are not responsible for independent clinical prioritization; that is the nurse’s role.

🟦 Delegation is based on the nurse’s priorities—not the AP’s.

The AP's rapport with the client

🟦 Rapport is helpful but not required for safe delegation.

🟦 Delegation must be based on competency and scope, not personality.

Whether the nurse can more efficiently and effectively complete the task

🟦 Delegation is not about efficiency—it’s about safe distribution of workload.

🟦 Even if the nurse can do it faster, the task may still be appropriate to delegate.

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Answer 10

Correct Answers:

Democratic

Rationale :

🟦 A democratic leadership style actively seeks team input, feedback, and shared decision-making, making it ideal for an in-service requiring participation.

🟦 It empowers staff to contribute ideas for reducing nosocomial infections, which increases engagement and ownership.

🟦 This style encourages collaboration, open discussion, and mutual problem solving among team members.

🟦 It improves motivation and teamwork by valuing each individual’s experience and perspective.

🟦 Democratic leadership is most effective when the goal is collective improvement and innovation.

Open-door

🟦 Open-door policy refers to communication approach, not a leadership style.

🟦 It does not inherently promote structured group participation.

Laissez-faire

🟦 This style offers minimal direction and often results in low productivity and poor coordination.

🟦 It is inappropriate when structured feedback and active involvement are needed.

Autocratic

🟦 Autocratic leaders make decisions without group input, which discourages participation.

🟦 This style suppresses feedback and is ineffective for brainstorming.

Distractor Analysis :

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QLexNursing

1 :
A nurse is working with an assistive personnel (AP) who refuses a client assignment. When resolving this conflict, which of the following comments is appropriate for the nurse to make?

2 :
A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

3 :
A nurse is receiving change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?

4 :
A charge nurse in a long-term care facility is reviewing client outcomes when delegating tasks to assistive personnel (AP) with a newly licensed nurse. Which of the following statements should the charge nurse include in the teaching?

5 :
A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which of the following statements should the nurse give?

6 :
A nurse on a medical-surgical unit is conducting a facility transfer with a client to an inpatient rehabilitation facility following a total hip replacement. Which of the following information should the nurse include in the transfer paperwork?

7 :
A nurse is reviewing disaster management with a newly licensed nurse. Which of the following actions should the nurse identify as being the responsibility of the nurse during a disaster?

8 :
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following tasks is unsafe to assign to an assistive personnel (AP)?

9 :
A nurse is caring for a group of clients with the help of an assistive personnel (AP). Which of the following determinations must the nurse make before delegating a client care task to the AP?

10 :
A nurse is planning an in-service that encourages active member participation and feedback about decreasing nosocomial infections on the unit. Which of the following leadership styles does the nurse plan to use?

QLexNursing

1 : A nurse is working with an assistive personnel (AP) who refuses a client assignment. When resolving this conflict, which of the following comments is appropriate for the nurse to make?

2 : A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

3 : A nurse is receiving change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?

4 : A charge nurse in a long-term care facility is reviewing client outcomes when delegating tasks to assistive personnel (AP) with a newly licensed nurse. Which of the following statements should the charge nurse include in the teaching?

5 : A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which of the following statements should the nurse give?

6 : A nurse on a medical-surgical unit is conducting a facility transfer with a client to an inpatient rehabilitation facility following a total hip replacement. Which of the following information should the nurse include in the transfer paperwork?

7 : A nurse is reviewing disaster management with a newly licensed nurse. Which of the following actions should the nurse identify as being the responsibility of the nurse during a disaster?

8 : A nurse is caring for a group of clients on a medical-surgical unit. Which of the following tasks is unsafe to assign to an assistive personnel (AP)?

9 : A nurse is caring for a group of clients with the help of an assistive personnel (AP). Which of the following determinations must the nurse make before delegating a client care task to the AP?

10 : A nurse is planning an in-service that encourages active member participation and feedback about decreasing nosocomial infections on the unit. Which of the following leadership styles does the nurse plan to use?

1 :
A nurse is working with an assistive personnel (AP) who refuses a client assignment. When resolving this conflict, which of the following comments is appropriate for the nurse to make?

2 :
A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

3 :
A nurse is receiving change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?

4 :
A charge nurse in a long-term care facility is reviewing client outcomes when delegating tasks to assistive personnel (AP) with a newly licensed nurse. Which of the following statements should the charge nurse include in the teaching?

5 :
A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which of the following statements should the nurse give?

6 :
A nurse on a medical-surgical unit is conducting a facility transfer with a client to an inpatient rehabilitation facility following a total hip replacement. Which of the following information should the nurse include in the transfer paperwork?

7 :
A nurse is reviewing disaster management with a newly licensed nurse. Which of the following actions should the nurse identify as being the responsibility of the nurse during a disaster?

8 :
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following tasks is unsafe to assign to an assistive personnel (AP)?

9 :
A nurse is caring for a group of clients with the help of an assistive personnel (AP). Which of the following determinations must the nurse make before delegating a client care task to the AP?

10 :
A nurse is planning an in-service that encourages active member participation and feedback about decreasing nosocomial infections on the unit. Which of the following leadership styles does the nurse plan to use?