1Question
A registered nurse (RN) on a medical-surgical unit is working with one unlicensed assistive personnel (UAP). Which task is appropriate for the RN to delegate to the UAP?
- Feeding a client who had a stroke yesterday and is waiting for a swallowing evaluation
- Measuring and recording the urinary catheter output of a stable client 2 days after surgery
- Teaching a client how to use an incentive spirometer for the first time
- Checking the reddened sacral area of a client on bed rest to see whether it has worsened
Show the answer and explanation
Answer: B. Measuring and recording the urinary catheter output of a stable client 2 days after surgery
Topic: tasks for UAP
Measuring and recording output is a routine, standardized task with a predictable result in a stable client, so it meets the right task and right circumstance. The RN keeps the parts of care that need nursing judgment: assessment, teaching and evaluation.
Why the others are wrong
- A – A client with a recent stroke and an unevaluated swallow is at high risk of aspiration; this is not a routine feeding and is not safe to delegate.
- C – Initial teaching requires nursing knowledge and evaluation of learning and stays with the RN.
- D – Deciding whether a skin area has worsened is assessment and evaluation, which cannot be delegated to a UAP.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
2Question
An RN is making assignments for the shift with a licensed practical/vocational nurse (LPN/LVN) on the team. Which client is most appropriate to assign to the LPN/LVN?
- A client admitted 20 minutes ago with chest pain who has not yet had an admission assessment
- A client going home today who needs first-time teaching on self-injection of insulin
- A client whose first unit of packed red blood cells was started 5 minutes ago
- A client with a chronic venous leg ulcer who needs a scheduled dressing change and oral medications
Show the answer and explanation
Answer: D. A client with a chronic venous leg ulcer who needs a scheduled dressing change and oral medications
Topic: assignment to LPN/LVN
An LPN/LVN cares for clients whose condition is stable and whose outcomes are predictable, carrying out established care such as scheduled dressing changes and oral medications. Initial assessment, initial teaching and care of clients who may change rapidly remain with the RN.
Why the others are wrong
- A – A new admission with chest pain is potentially unstable and needs the RN's initial comprehensive assessment.
- B – Initial discharge teaching is an RN responsibility; an LPN/LVN may reinforce teaching that has already been given.
- C – The first minutes of a transfusion are the period of highest risk for a reaction and need RN assessment and monitoring.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
3Question
An RN is deciding which tasks to delegate to an experienced unlicensed assistive personnel (UAP). Which tasks are appropriate to delegate?
Select all that apply.
- Walking a stable client in the hallway 3 days after hip replacement, as already established with physical therapy
- Asking a client to rate pain 30 minutes after an opioid and deciding whether the dose worked
- Emptying an established colostomy pouch and recording the amount
- Giving a bed bath to a client who is on contact precautions
- Explaining to a client why a low-sodium diet has been newly prescribed
- Confirming placement of a nasogastric tube before a feeding is started
Show the answers and explanation
Answers: A, C and D.
- A – Walking a stable client in the hallway 3 days after hip replacement, as already established with physical therapy
- C – Emptying an established colostomy pouch and recording the amount
- D – Giving a bed bath to a client who is on contact precautions
Topic: tasks for UAP
UAP may carry out routine activities of daily living, ambulation of stable clients and measurement of output, because these follow a fixed procedure and have predictable results. Isolation precautions do not change this, as UAP are trained in them. Evaluating a response to medication, teaching, and verifying tube placement need nursing judgment.
Why the others are wrong
- B – Judging whether an analgesic has been effective is evaluation, which stays with the nurse.
- E – Explaining a newly prescribed diet is initial teaching and cannot be delegated to a UAP.
- F – Confirming tube placement is an assessment with serious risk if wrong and is a licensed nurse's responsibility.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
4Question
An RN delegated routine vital signs to a UAP. The UAP reports that a client who had bowel surgery yesterday has a blood pressure of 88/50 mm Hg; the reading 4 hours ago was 126/78 mm Hg. Which action should the RN take first?
- Ask the UAP to repeat the blood pressure in 15 minutes and report again
- Call the surgeon to report the blood pressure
- Go to the client and assess the client's condition
- Record the reading in the chart and compare it with the next scheduled reading
Show the answer and explanation
Answer: C. Go to the client and assess the client's condition
Topic: supervision and follow-up
Delegating a task does not delegate the assessment. An unexpected change reported by a UAP requires the RN to assess the client personally and without delay; the RN's findings then guide what is reported to the provider.
Why the others are wrong
- A – Sending the UAP back delays assessment of a possibly bleeding or hypovolemic client and leaves judgment with the UAP.
- B – The provider will need to be told, but the RN must first assess so that the report is complete and accurate.
- D – Waiting for the next scheduled reading ignores a significant unexpected change after surgery.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
5Question
An RN is delegating blood pressure monitoring for a stable client to a UAP. Which instruction best meets the right of direction and communication?
- 'Take the blood pressure of the client in room 4 every 30 minutes until noon, and tell me right away if the top number is below 100 or above 160.'
- 'Take vital signs on the client in room 4 this morning and let me know if anything seems off.'
- 'Keep a close eye on the client in room 4 and check the blood pressure as often as you think is needed.'
- 'The client in room 4 needs frequent blood pressure checks; chart them and I will look at them later.'
Show the answer and explanation
Answer: A. 'Take the blood pressure of the client in room 4 every 30 minutes until noon, and tell me right away if the top number is below 100 or above 160.'
Topic: five rights: direction and communication
The right direction and communication means a clear, specific instruction: what to do, for which client, how often and for how long, and exactly which findings to report and when. Specific limits remove the need for the UAP to interpret the results.
Why the others are wrong
- B – 'Anything seems off' leaves the UAP to judge what is abnormal, which is not within the UAP's role.
- C – Letting the UAP decide the frequency transfers nursing judgment to the UAP.
- D – It gives no frequency and no findings to report, and puts off the RN's follow-up.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
6Question
A newly licensed RN asks the charge nurse what the RN is responsible for after delegating a task to a UAP. Which statements by the charge nurse are accurate?
Select all that apply.
- 'When the UAP accepts the task, the nursing judgment that goes with it passes to the UAP.'
- 'You remain accountable for the client's overall care and for the decision to delegate.'
- 'The UAP is responsible for carrying out the task as directed and for telling you if unable to do it.'
- 'If the UAP is busy, the UAP may hand the task on to another UAP.'
- 'Delegate only tasks that are in the UAP's job description and in which the UAP's competence has been validated.'
- 'You need to follow up, evaluate the result and the client's response.'
Show the answers and explanation
Answers: B, C, E and F.
- B – 'You remain accountable for the client's overall care and for the decision to delegate.'
- C – 'The UAP is responsible for carrying out the task as directed and for telling you if unable to do it.'
- E – 'Delegate only tasks that are in the UAP's job description and in which the UAP's competence has been validated.'
- F – 'You need to follow up, evaluate the result and the client's response.'
Topic: accountability in delegation
Under the national delegation guidelines the licensed nurse keeps accountability for the client and for the delegation decision, while the delegatee is responsible for performing the accepted activity correctly. Only tasks within the delegatee's role and validated competence may be delegated, and the nurse must supervise and evaluate. Nursing judgment is never delegated, and a delegatee may not re-delegate.
Why the others are wrong
- A – Nursing judgment and critical decision making cannot be delegated; only the performance of the task is transferred.
- D – A delegated task may not be passed on by the delegatee; only the licensed nurse decides who performs it.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
7Question
An RN is working with an LPN/LVN and a UAP. Which activity should the RN perform personally?
- Giving scheduled oral medications to a client whose condition is stable
- Reinforcing crutch-walking instructions that the client received yesterday
- Developing the discharge teaching plan for a client newly diagnosed with heart failure
- Inserting an indwelling urinary catheter in a stable client before a procedure
Show the answer and explanation
Answer: C. Developing the discharge teaching plan for a client newly diagnosed with heart failure
Topic: RN-only responsibilities
Developing a plan of care or teaching plan requires comprehensive assessment and nursing judgment and is the RN's responsibility. An LPN/LVN contributes to the plan and may carry out established care for stable clients.
Why the others are wrong
- A – Oral medications for a stable client are within the LPN/LVN's usual practice.
- B – Reinforcing teaching that has already been given may be assigned to an LPN/LVN.
- D – Urinary catheter insertion in a stable client is a technical skill within the LPN/LVN's usual practice.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
8Question
An RN asks a UAP to apply sequential compression devices to a stable client after surgery. The UAP says, 'I have never put those on before.' Which response by the RN is best?
- 'They are simple; the instructions are printed on the package.'
- 'I will show you on this client and then watch you apply them.'
- 'Ask one of the other assistants to show you when they have time.'
- 'Then I will note that you declined the task.'
Show the answer and explanation
Answer: B. 'I will show you on this client and then watch you apply them.'
Topic: five rights: right person
The right person means the delegatee has the skill and validated competence for the task. When a UAP states a lack of experience, the RN must teach and directly observe the skill, or perform the task or reassign it, before relying on the UAP.
Why the others are wrong
- A – Reading a package does not establish competence, and the RN would be delegating to a person known to be unprepared.
- C – Another UAP cannot validate competence; the nurse who delegates is responsible for confirming it.
- D – Speaking up about lack of competence is the UAP's duty, not a refusal; treating it as one discourages safe reporting and leaves the task undone.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
9Question
A registered nurse who normally works on an adult medical-surgical unit is floated to the postpartum unit for one shift. Which client should the charge nurse assign to this nurse?
- A client who gave birth vaginally 1 hour ago and has a boggy fundus
- A client with preeclampsia who is receiving a magnesium sulfate infusion
- A client 2 days after a cesarean birth who has stable vital signs and needs incision care and oral analgesics
- A newborn receiving phototherapy whose mother needs help with breastfeeding
Show the answer and explanation
Answer: C. A client 2 days after a cesarean birth who has stable vital signs and needs incision care and oral analgesics
Topic: assignment for a float nurse
A float nurse is given clients whose needs are closest to the nurse's usual practice and who are stable. Care of a stable client after abdominal surgery, with incision care and pain management, matches medical-surgical competence. The other clients need specialty assessment skills.
Why the others are wrong
- A – A boggy fundus in the first hour signals a risk of postpartum hemorrhage and needs a nurse skilled in fundal assessment.
- B – Magnesium sulfate for preeclampsia needs close specialty monitoring of reflexes, respirations and output.
- D – Newborn phototherapy and lactation support are outside the float nurse's usual competence.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
10Question
A charge nurse is making the client assignments for a shift. The team includes a registered nurse who finished orientation 2 weeks ago and a float nurse. Which factors should guide the assignments?
Select all that apply.
- The acuity and stability of each client
- The experience and demonstrated competence of each staff member
- Continuity of care, such as which nurse cared for the client on previous shifts
- Each staff member's request for the clients who need the least care
- Length of employment, so that the most senior nurses receive the fewest clients
- Infection control, so that one nurse is not caring for both a client with a transmissible infection and a severely immunosuppressed client when this can be avoided
Show the answers and explanation
Answers: A, B, C and F.
- A – The acuity and stability of each client
- B – The experience and demonstrated competence of each staff member
- C – Continuity of care, such as which nurse cared for the client on previous shifts
- F – Infection control, so that one nurse is not caring for both a client with a transmissible infection and a severely immunosuppressed client when this can be avoided
Topic: making assignments by acuity and competence
Assignments match what clients need with what each staff member is competent to provide. Acuity, staff competence, continuity of care and infection control are recognized factors. A newly oriented nurse and a float nurse receive stable clients within their competence, with a resource person available.
Why the others are wrong
- D – Preferences for an easier workload do not match client needs to skills and distribute work unfairly.
- E – Seniority is not a measure of what clients need; experienced nurses are usually given the more complex clients.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
11Question
A charge nurse is assigning clients on a medical unit. Which client is most appropriate to assign to the LPN/LVN?
- A client with residual weakness from a stroke 3 months ago who needs gastrostomy tube feedings and scheduled medications by the tube
- A client admitted 1 hour ago with diabetic ketoacidosis who is receiving an insulin infusion
- A client newly diagnosed with colon cancer who needs initial teaching about an ostomy before surgery tomorrow
- A client who returned from a cardiac catheterization 30 minutes ago
Show the answer and explanation
Answer: A. A client with residual weakness from a stroke 3 months ago who needs gastrostomy tube feedings and scheduled medications by the tube
Topic: assignment to the LPN/LVN
The LPN/LVN cares for clients whose condition is stable and whose outcomes are predictable, carrying out established procedures such as tube feedings and routine medications under the direction of the registered nurse. Clients who are unstable, newly admitted, fresh from an invasive procedure or in need of initial teaching require the registered nurse.
Why the others are wrong
- B – A new admission in ketoacidosis on an insulin infusion is unstable and needs frequent registered nurse assessment.
- C – Initial teaching requires assessment of learning needs and planning by the registered nurse; the LPN/LVN reinforces teaching.
- D – Thirty minutes after catheterization the client is at risk of bleeding and vascular complications and needs registered nurse assessment.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
12Question
A nurse on a postpartum unit is working with experienced unlicensed assistive personnel (UAP). Which tasks are appropriate to delegate to the UAP?
Select all that apply.
- Taking routine vital signs of a client 6 hours after an uncomplicated vaginal birth
- Checking the fundus and lochia of a client who gave birth 1 hour ago
- Helping a client 12 hours after cesarean birth walk to the bathroom for the second time
- Showing a first-time mother how to correct a painful latch
- Counting a client's perineal pads and telling the nurse at once if one is soaked in less than an hour
- Deciding whether a newborn's yellow skin color needs to be reported to the provider
Show the answers and explanation
Answers: A, C and E.
- A – Taking routine vital signs of a client 6 hours after an uncomplicated vaginal birth
- C – Helping a client 12 hours after cesarean birth walk to the bathroom for the second time
- E – Counting a client's perineal pads and telling the nurse at once if one is soaked in less than an hour
Topic: delegation on a postpartum unit
UAP may carry out routine, standard tasks on stable clients and collect data with clear instructions about what to report. Vital signs on a stable client, a repeat ambulation after the nurse has done the first one, and counting pads with a stated reporting limit fit this. Assessment of the fundus and lochia, teaching, and judging a newborn's jaundice need a nurse's knowledge and cannot be delegated.
Why the others are wrong
- B – The first hours after birth carry the highest risk of hemorrhage; fundus and lochia checks are nursing assessment.
- D – Correcting a latch requires assessment and teaching, which stay with the nurse or a lactation specialist.
- F – Judging the meaning of a finding is clinical judgment; the UAP reports what is seen, the nurse decides.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
13Question
A registered nurse from an adult medical-surgical unit is floated to a pediatric unit for the shift. Which client should the pediatric charge nurse assign to this nurse?
- A 2-year-old with suspected epiglottitis who is drooling and sitting forward
- A 6-year-old with newly diagnosed type 1 diabetes whose parents need to learn insulin administration
- A 14-year-old who has been in skeletal traction for a fractured femur for 3 days and is stable
- A 3-month-old with fever who is waiting for a lumbar puncture
Show the answer and explanation
Answer: C. A 14-year-old who has been in skeletal traction for a fractured femur for 3 days and is stable
Topic: assignment for a floated nurse
A floated nurse should be given clients whose care is closest to the nurse's usual practice and whose condition is stable and predictable. An adolescent in skeletal traction needs neurovascular checks, pin care and pain control, skills an adult medical-surgical nurse uses regularly, and adolescent body size and drug dosing are closest to an adult's.
Why the others are wrong
- A – A possible airway emergency in a toddler needs a nurse experienced in pediatric airway care.
- B – Teaching parents of a child with new diabetes needs pediatric knowledge of dosing, growth and family education.
- D – Assessing a febrile young infant and assisting with the procedure require pediatric assessment skills.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
14Question
A nurse on an inpatient mental health unit is planning the shift with unlicensed assistive personnel (UAP) who is trained as a mental health technician. Which tasks may the nurse delegate to the UAP?
Select all that apply.
- Staying within arm's length of a client who is on one-to-one observation for suicide risk
- Checking a newly admitted client's belongings against the unit's list of prohibited items
- Evaluating whether a client's command hallucinations have lessened since the medication was changed
- Teaching a client who has just started lithium the signs of toxicity
- Walking a group of stable clients to the dining room and reporting anyone who does not eat
- Deciding whether a client can be moved from checks every 15 minutes to routine observation
Show the answers and explanation
Answers: A, B and E.
- A – Staying within arm's length of a client who is on one-to-one observation for suicide risk
- B – Checking a newly admitted client's belongings against the unit's list of prohibited items
- E – Walking a group of stable clients to the dining room and reporting anyone who does not eat
Topic: delegation on a mental health unit
Continuous observation, a belongings check done from a set list, and escorting stable clients while reporting a defined observation are standard tasks with predictable results, suitable for trained UAP. Evaluating a response to treatment, teaching about a new medication, and changing a level of observation require assessment and judgment, which remain with the nurse and the treatment team.
Why the others are wrong
- C – Evaluating the effect of treatment on symptoms is assessment and evaluation, the nurse's part of the nursing process.
- D – Initial teaching about a new medication is the nurse's responsibility.
- F – Reducing a level of observation is a clinical decision based on a risk assessment, not a delegated task.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
15Question
A nurse in a long-term care facility told unlicensed assistive personnel (UAP) at the start of the shift to turn a resident who cannot move independently every 2 hours. Four hours later the nurse finds the resident in the same position, with a reddened area over the sacrum that does not blanch when pressed. What should the nurse do first?
- Reposition the resident off the sacrum and assess the skin
- Find the UAP and ask why the resident was not turned
- Complete an incident report about the missed care
- Report the UAP's performance to the director of nursing
Show the answer and explanation
Answer: A. Reposition the resident off the sacrum and assess the skin
Topic: delegated task not carried out
The nurse remains accountable for the outcome of a delegated task, and the resident's immediate need comes first: relieve the pressure and assess the injury. Redness that does not blanch is a stage 1 pressure injury. Afterward the nurse talks with the UAP in private to learn what went wrong, clarifies expectations, documents, and follows facility policy for reporting.
Why the others are wrong
- B – This conversation is needed, but it leaves the resident lying on injured skin while it takes place.
- C – Documentation follows care of the resident; a report does not relieve the pressure.
- D – Going to the director before caring for the resident and hearing the UAP's account is premature.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
16Question
A home health aide telephones the supervising nurse from the home of a client with heart failure. The aide says the client's weight log shows a gain of 4 lb (1.8 kg) since the aide's visit 2 days ago and that the client's shoes no longer fit. The nurse's next scheduled visit is in 3 days. Which response by the nurse is best?
- 'Tell the client to drink much less for the rest of the week, and I will check the weight at my next visit.'
- 'Give the client one extra furosemide tablet from the bottle today.'
- 'Listen to the client's lungs and call me back with what you hear.'
- 'Thank you for calling. I will come to assess the client today.'
Show the answer and explanation
Answer: D. 'Thank you for calling. I will come to assess the client today.'
Topic: supervising a home health aide
A rapid weight gain with new swelling in a client with heart failure means fluid is being retained and the condition is getting worse. The aide has done the right thing by observing and reporting; the nurse must now assess the client the same day and contact the provider. The aide cannot assess, change medication or give medical advice.
Why the others are wrong
- A – It delays assessment of worsening heart failure by three days and has the aide pass on a treatment change no provider has prescribed.
- B – Changing a medication dose needs a provider's prescription, and neither the aide nor the nurse may decide it alone.
- C – Listening to lung sounds is an assessment that is outside the aide's role.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
17Question
An LPN/LVN from a staffing agency arrives for a first shift on a surgical unit. The charge nurse is considering assigning the LPN/LVN a stable client who needs an intravenous piggyback antibiotic through a peripheral line. Which actions should the charge nurse take when making this assignment?
Select all that apply.
- Confirm that the nurse practice act and the facility's policy allow an LPN/LVN to give this medication by this route
- Check the competency record supplied by the agency and orient the LPN/LVN to the unit's infusion pumps
- Ask the LPN/LVN about experience with intravenous piggyback medications
- State what the LPN/LVN should report and when
- Assume competence, because the agency is responsible for screening its staff
- Have the LPN/LVN complete the admission assessment of a new client to free the registered nurses
Show the answers and explanation
Answers: A, B, C and D.
- A – Confirm that the nurse practice act and the facility's policy allow an LPN/LVN to give this medication by this route
- B – Check the competency record supplied by the agency and orient the LPN/LVN to the unit's infusion pumps
- C – Ask the LPN/LVN about experience with intravenous piggyback medications
- D – State what the LPN/LVN should report and when
Topic: checks before assigning agency staff
Before assigning or delegating, the nurse confirms that the task is within the person's legal scope and the employer's policy, that the person is competent to do it in this setting, and that the directions are clear. Agency employment does not remove the charge nurse's duty to verify. The initial admission assessment belongs to the registered nurse.
Why the others are wrong
- E – The agency screens staff in general, but the nurse who makes the assignment must still verify competence for this task on this unit.
- F – The initial, comprehensive assessment of a newly admitted client is a registered nurse responsibility.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
18Question
A nurse is supervising unlicensed assistive personnel (UAP) caring for a client on the second day after a total knee replacement. Which action by the UAP requires the nurse to intervene?
- Reminding the client to pump the ankles up and down while resting in bed
- Tucking a pillow under the operated knee so it rests bent while the client naps
- Walking beside the client who is using a walker to go to the bathroom
- Reapplying the prescribed cold pack over the knee after the exercise session
Show the answer and explanation
Answer: B. Tucking a pillow under the operated knee so it rests bent while the client naps
Topic: total knee replacement positioning
A pillow under the operated knee holds it flexed and encourages a flexion contracture, which limits the ability to straighten the leg and walk normally. The knee is kept in extension when at rest; if elevation is needed the whole lower leg is supported from the calf or heel.
Why the others are wrong
- A – Ankle pumps promote venous return and lower the risk of deep vein thrombosis; this is expected care.
- C – Early assisted walking with a walker is expected and within the UAP's role for a stable client.
- D – Cold therapy after exercise reduces swelling and pain and is commonly prescribed after knee replacement.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
19Question
A nurse is assigning breakfast assistance on a medical unit to a UAP. For which clients is it appropriate for the UAP to set up the tray and help with the meal?
Select all that apply.
- A client recovering from pneumonia who is alert and has no swallowing difficulty
- A client admitted with a stroke yesterday whose swallowing has not yet been evaluated
- A client with severe arthritis who needs the tray opened and the food cut up
- A client with a history of aspiration who coughs when drinking thin liquids
- A client who is drowsy and difficult to arouse after a sedating medication
Show the answers and explanation
Answers: A and C.
- A – A client recovering from pneumonia who is alert and has no swallowing difficulty
- C – A client with severe arthritis who needs the tray opened and the food cut up
Topic: UAP meal assistance eligibility
A UAP may help clients who are stable, alert and have a predictable, uncomplicated need, such as setting up a tray or cutting food. Clients with a possible or known swallowing problem or a decreased level of consciousness are at risk for aspiration, so feeding them requires a nurse's assessment and a plan, often with a swallowing evaluation first.
Why the others are wrong
- B – A new stroke can impair swallowing, and until it has been evaluated the nurse must assess the client and decide on diet and feeding precautions.
- D – Coughing with thin liquids in a client with prior aspiration shows an active swallowing problem; the nurse must plan feeding with the team and the speech-language pathologist.
- E – A drowsy client cannot protect the airway during eating, so the meal should be held until the nurse has assessed the client's alertness.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
20Question
A client with newly diagnosed heart failure is being prepared for discharge. The RN has completed the teaching plan and the first teaching session. Which teaching activity is most appropriate to assign to the LPN/LVN?
- Reassess the client's learning needs and revise the discharge teaching plan
- Teach the client for the first time about the purpose and adverse effects of the new diuretic
- Reinforce the RN's earlier instructions about weighing daily and recording the weights
- Evaluate whether the client has met the teaching goals and document the final outcome
Show the answer and explanation
Answer: C. Reinforce the RN's earlier instructions about weighing daily and recording the weights
Topic: initial versus reinforcing teaching
The RN is responsible for assessing learning needs, planning, giving initial teaching about new content and evaluating the result. The LPN/LVN can reinforce teaching that the RN has already given, following the established plan, and report the client's responses.
Why the others are wrong
- A – Reassessing needs and revising the plan is assessment and planning, which only the RN performs.
- B – Initial teaching of new medication content requires RN knowledge and judgement and cannot be assigned.
- D – Evaluating whether goals are met is an RN responsibility; the LPN/LVN can contribute observations.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
21Question
At the start of the shift a UAP gives the RN the observations below. Which reports require the RN to follow up promptly with an assessment?
Select all that apply.
- A client ate about three quarters of the breakfast
- A client 1 day after surgery says, 'Something terrible is about to happen,' and looks pale and sweaty
- A client on bed rest is resting quietly with the call light within reach
- A client with diabetes has a fingerstick glucose reading of 54 mg/dL
- A client admitted with a stroke had clear speech yesterday and is slurring words today
- A client asks for an extra pillow for comfort
Show the answers and explanation
Answers: B, D and E.
- B – A client 1 day after surgery says, 'Something terrible is about to happen,' and looks pale and sweaty
- D – A client with diabetes has a fingerstick glucose reading of 54 mg/dL
- E – A client admitted with a stroke had clear speech yesterday and is slurring words today
Topic: UAP reports needing RN follow-up
UAP report what they observe, and the RN interprets it. A sense of doom with pallor and sweating after surgery may signal hemorrhage, shock or embolism, a glucose of 54 mg/dL is hypoglycemia, and new slurred speech in a stroke client suggests neurologic deterioration. These are unexpected changes that need an RN assessment now.
Why the others are wrong
- A – Eating most of a meal is an expected, reassuring finding that can be recorded.
- C – A quiet client with the call light in reach is a safe, routine situation.
- F – An extra pillow is a comfort request the UAP can meet.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
22Question
A staff nurse is working with a nursing student who is assigned to one of the nurse's clients. The student asks to hang a heparin infusion, a skill that the student's school has not yet taught or approved for student performance. What is the nurse's best response?
- Allow the student to hang it while the nurse watches closely and co-signs the documentation
- Let the student prepare the infusion and have the nurse connect it to the client's line
- Allow it, because the staff nurse holds the license and remains responsible for the outcome
- Explain that students perform only skills the school has approved and checked off, and invite the student to observe
Show the answer and explanation
Answer: D. Explain that students perform only skills the school has approved and checked off, and invite the student to observe
Topic: nursing student skill outside approved list
Nursing students practice within the skills their program has taught and validated, under the supervision of the instructor. A staff nurse cannot expand that list, and heparin is a high-alert medication. Offering the student an observation role keeps the client safe and the learning opportunity.
Why the others are wrong
- A – Close watching does not make the skill approved, and co-signing does not fix a scope problem.
- B – Preparing the infusion is still performing an unapproved part of a high-alert medication task.
- C – The nurse's license does not extend the student's scope, and the nurse would also be accountable for permitting it.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
23Question
A charge nurse is making assignments for a newly licensed RN who finished unit orientation last week. Which client assignment is most appropriate for this nurse?
- A client with a new chest tube for a pneumothorax and a client being admitted from the emergency department with unstable chest pain
- A client who is receiving a blood transfusion and a client who is actively vomiting blood
- A client recovering from knee replacement who walks with a walker and a client with stable heart failure awaiting discharge teaching
- A client with a new colostomy and a client in alcohol withdrawal who is hallucinating with unstable vital signs
Show the answer and explanation
Answer: C. A client recovering from knee replacement who walks with a walker and a client with stable heart failure awaiting discharge teaching
Topic: assignment for a newly licensed nurse
A newly licensed nurse should be given clients who are stable and have predictable needs, with unstable or complex clients shared with experienced nurses. This lets the new nurse build skill in time management and assessment with support close by.
Why the others are wrong
- A – A new chest tube plus an unstable admission combines two clients who may need rapid, experienced judgement.
- B – A client who is vomiting blood is unstable and a transfusion requires close monitoring; both exceed this nurse's current experience.
- D – A client in withdrawal with unstable vital signs is high risk and should be assigned to an experienced nurse.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
24Question
A charge nurse is making assignments on an oncology unit. One of the RNs is in the first trimester of pregnancy. Which client should the charge nurse avoid assigning to this nurse?
- A client 2 days after mastectomy who has a closed-suction drain to empty and measure
- A client who is receiving an intravenous chemotherapy drug that is classified as hazardous
- A client who is neutropenic and on protective precautions with a central line dressing due
- A client with pain from bone metastases who needs a scheduled oral opioid
Show the answer and explanation
Answer: B. A client who is receiving an intravenous chemotherapy drug that is classified as hazardous
Topic: assignment of a pregnant nurse
Hazardous antineoplastic drugs can be harmful to a developing fetus, and occupational safety guidance advises that staff who are pregnant or trying to conceive be given the option of avoiding handling them. The other assignments do not carry this exposure.
Why the others are wrong
- A – Emptying a surgical drain involves standard precautions only and no reproductive hazard.
- C – Caring for a neutropenic client uses protective precautions that protect the client, not a hazard to the nurse.
- D – Giving a scheduled oral opioid carries no special fetal hazard for the nurse.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
25Question
A client has an indwelling urinary catheter. Which tasks may the RN delegate to a UAP?
Select all that apply.
- Empty the drainage bag at the end of the shift and record the amount
- Irrigate the catheter with sterile saline when the drainage slows
- Clean the perineal area and the catheter near the meatus with soap and water
- Evaluate cloudy, foul-smelling urine and decide whether the provider should be called
- Insert a new catheter if the old one comes out
Show the answers and explanation
Answers: A and C.
- A – Empty the drainage bag at the end of the shift and record the amount
- C – Clean the perineal area and the catheter near the meatus with soap and water
Topic: UAP tasks with an indwelling catheter
Emptying a drainage bag, recording output and routine perineal hygiene are routine, predictable tasks within the UAP's training. Irrigation and insertion are sterile invasive procedures, and judging whether urine findings need a provider is assessment and clinical judgement, all of which stay with the nurse.
Why the others are wrong
- B – Irrigation is a sterile procedure that requires nursing knowledge and often an order.
- D – Evaluating findings and deciding to notify the provider is assessment and cannot be delegated; the UAP reports what is seen.
- E – Catheter insertion is a sterile invasive procedure that the nurse performs.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
NCLEX-RN is a registered trademark of the National Council of State Boards of Nursing, Inc. (NCSBN). This site is not affiliated with, sponsored by or endorsed by the owner of that mark.
Nursing