Question

A nurse is working with an assistive personnel (AP) in a health clinic during an outbreak of influenza. Which of the following tasks should the nurse delegate to the AP?

Answer 1

Correct Answers:

Perform a simple dressing change for a client.

Rationale :

🧨Assistive personnel (APs) are trained to perform non-invasive, routine tasks that do not require nursing judgment.

🧨A simple dressing change, such as changing a dry, intact dressing with no complications, can be safely delegated depending on facility policy and the AP's training.

🧨This task is considered within the scope of a competent AP, especially during high-demand periods like an influenza outbreak, when efficient delegation is essential to manage care volume.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Change peripheral IV primary tubing every 96 hr.

Rationale :

✔The recommendation to change peripheral IV tubing every 96 hours is supported by evidence-based guidelines from the Centers for Disease Control and Prevention (CDC) for reducing the risk of central line-associated bloodstream infections (CLABSIs).

✔ This timeframe maintains a balance between infection prevention and cost-effective care.

✔ Changing tubing more frequently than 96 hours does not significantly reduce infection rates but increases supply use and costs.

✔On the other hand, waiting longer than 96 hours increases the risk of microbial colonization and bloodstream infections.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Clean gloves are discarded after removing the old dressing.

Rationale :

✅The act of removing soiled gloves before proceeding to handle new sterile supplies demonstrates a sound understanding of aseptic technique and infection control.

✅ Using the same gloves throughout the wound care procedure can lead to cross-contamination, which increases the client's risk for wound infection.

✅Best practice requires that gloves used to remove a dirty dressing be discarded, and new gloves or sterile gloves be applied before accessing sterile items or cleaning the wound.

✅This step is essential in maintaining a sterile field and promoting safe client outcomes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

A client who has a compromised airway

Rationale :

⭐During a mass casualty event, the use of triage tags allows healthcare providers to prioritize care based on urgency and survival potential.

⭐A red tag indicates immediate intervention is needed to save a life.

⭐ A client with a compromised airway is at risk of respiratory failure or death if not treated promptly.

⭐Establishing or securing the airway is a top priority in trauma and emergency care.

⭐In contrast, other options such as fixed pupils or 70% burns are associated with expectant care (black tag), while brief loss of consciousness may fall under delayed or minimal care (yellow or green).

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

HbAIC numbers decreased

Rationale :

🥟The Hemoglobin A1C (HbA1C) test provides a snapshot of a client’s average blood glucose level over the past 2–3 months, making it the most reliable indicator of long-term diabetes management.

🥟A decrease in HbA1C values signifies improved glycemic control, which is a direct outcome of effective client education on insulin self-administration, lifestyle changes, and medication adherence.

🥟This is a meaningful metric for evaluating the effectiveness of a diabetes teaching initiative, whereas increased blood glucose or incidents of lipohypertrophy would suggest the teaching has not been successful.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Critical pathway

Rationale :

🔶A critical pathway is a standardized, evidence-based, multidisciplinary plan that outlines the expected progression of care for a specific diagnosis or procedure.

🔶It provides a clear timeline for interventions such as catheter removal after colon resection.

🔶Using a critical pathway helps streamline care, reduce variation in practice, and improve efficiency and outcomes by promoting consistency with best practices.

🔶This is the most appropriate tool for developing standards of care for common surgical procedures.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Notify the provider about the client's concerns-

Rationale :

💨The nurse’s role in informed consent includes verifying that the client has received adequate information from the provider and ensuring that the client understands the risks, benefits, and alternatives before proceeding.

💨If the client expresses concern or demonstrates a lack of understanding, the nurse must advocate by notifying the provider.

💨It is outside the nurse’s scope to explain procedural risks, which is the provider’s responsibility. This ensures ethical and legal compliance with informed consent requirements.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Elevates the head of the client’s bed to 30° before inserting a nasogastric tube

Rationale :

☀For safe insertion of a nasogastric (NG) tube, the client should be positioned with the head of the bed elevated to at least 45°.

☀This reduces the risk of aspiration and promotes easier passage of the tube into the esophagus rather than the airway.

☀Elevating the bed only to 30° is insufficient, especially in clients at risk for gastric reflux or respiratory complications.

☀The charge nurse should intervene immediately to correct this positioning error and reinforce proper technique.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

A toddler who cries whenever their parent enters the examination room

Rationale :

🦠A child’s behavior can be a non-verbal indicator of maltreatment, especially when it is specifically triggered by a caregiver’s presence.

🦠Crying at the mere sight of the parent suggests fear-based conditioning, possibly from abuse or neglect.

🦠Unlike other responses (e.g., adolescent refusal to speak or toilet regression), this behavior is more emotionally specific and concerning.

🦠The nurse must follow mandatory reporting laws and notify the appropriate child protective services.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Document nursing interventions as they are completed.

Rationale :

🔦Timely documentation is a fundamental part of efficient time management and ensures accuracy, continuity of care, and legal protection.

🔦Documenting after completing each task prevents omissions, delays, and memory errors.

🔦Waiting to chart all at once or skipping breaks compromises care quality and nurse well-being.

🔦Prioritizing based on urgency while staying up to date on documentation reflects safe and organized practice.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

RN Leadership Retake 2023

No.

1 :
A nurse is working with an assistive personnel (AP) in a health clinic during an outbreak of influenza. Which of the following tasks should the nurse delegate to the AP?

2 :
A nurse is serving on a committee whose task is to plan cost- effective care at the facility. Which of the following client care tasks should the nurse recommend?

3 :
A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?

4 :
A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?

5 :
A nurse implemented a new method of teaching clients about self-administration of insulin six months ago. Which of the following findings indicates the new method is effective?

6 :
A nurse is planning to develop a standard for removal of indwelling urinary catheters from clients following colon resection. Which of the following resources should the nurse

7 :
A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take?

8 :
A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

9 :
A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?

10 :
A nurse is caring for a group of clients on the surgical floor. Which of the following actions should the nurse take to organize their workload and manage time efficiently?

Connect With Us

RN Leadership Retake 2023

No.

1 : A nurse is working with an assistive personnel (AP) in a health clinic during an outbreak of influenza. Which of the following tasks should the nurse delegate to the AP?

2 : A nurse is serving on a committee whose task is to plan cost- effective care at the facility. Which of the following client care tasks should the nurse recommend?

3 : A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?

4 : A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?

5 : A nurse implemented a new method of teaching clients about self-administration of insulin six months ago. Which of the following findings indicates the new method is effective?

6 : A nurse is planning to develop a standard for removal of indwelling urinary catheters from clients following colon resection. Which of the following resources should the nurse

7 : A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take?

8 : A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

9 : A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?

10 : A nurse is caring for a group of clients on the surgical floor. Which of the following actions should the nurse take to organize their workload and manage time efficiently?

1 :
A nurse is working with an assistive personnel (AP) in a health clinic during an outbreak of influenza. Which of the following tasks should the nurse delegate to the AP?

2 :
A nurse is serving on a committee whose task is to plan cost- effective care at the facility. Which of the following client care tasks should the nurse recommend?

3 :
A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?

4 :
A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?

5 :
A nurse implemented a new method of teaching clients about self-administration of insulin six months ago. Which of the following findings indicates the new method is effective?

6 :
A nurse is planning to develop a standard for removal of indwelling urinary catheters from clients following colon resection. Which of the following resources should the nurse

7 :
A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take?

8 :
A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

9 :
A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?

10 :
A nurse is caring for a group of clients on the surgical floor. Which of the following actions should the nurse take to organize their workload and manage time efficiently?