NR-224 Fundamentals – Skills - Set 1 - Part 2

Correct Answer: Interviewing the client alone for part of it

Adolescents do not disclose sexual activity, substance use, mood or safety concerns with a parent in the room. Part of the encounter is conducted alone, after explaining what stays confidential and what must be reported. Option a is incorrect because a parent cannot answer for experiences the adolescent has never shared at home. The mother's account of substance use or sexual activity would be a guess presented as history. Option b is incorrect because continuous parental presence guarantees an edited history. The adolescent answers to protect the relationship at home rather than to inform the nurse, and the gaps never appear in the record. Option d is incorrect because deferral treats a solvable seating problem as a scheduling problem. Risk behaviour, mood and safety belong in this admission database, and an inpatient adolescent may never attend the follow-up visit.

Correct Answer: Repositioning the client onto the left side

Repositioning is a nursing action carried out to change the client's condition, which places it in implementation. Verbs such as reposition, administer, teach and assist describe doing the plan rather than gathering the data behind it. Option a is incorrect because auscultation gathers information through the nurse's senses, which is a hallmark assessment verb. Listening to bowel sounds tells the nurse what is happening without changing anything about the client's condition. Option c is incorrect because interviewing is how subjective data enter the database, placing it squarely in the first step. A medication history informs later decisions, but collecting it is not yet an intervention. Option d is incorrect because measuring produces a number that describes the wound, and measurement verbs sit with assessment. Nothing about recording a dimension alters the wound or advances the plan of care.

Correct Answer: Tell the charge nurse about the training gap

The nurse states the specific competency gap to the charge nurse before care begins, so the assignment can be adjusted or support arranged. Accepting work she cannot safely perform places both the clients and her license at risk. Option b is incorrect because delay leaves two monitored clients without anyone able to recognize a dangerous rhythm. Informal help from a coworker who has her own assignment is not a substitute for a workable assignment. Option c is incorrect because walking off the unit after report has begun is client abandonment and carries its own board discipline. Raising a concern through the chain of command is the professional route. Option d is incorrect because ignoring the monitors does not make the clients safer; it simply hides the gap. Continuous monitoring exists to catch deterioration early, and someone competent must be watching it every hour of the shift.

Correct Answer: "What has your breathing been like these past weeks?"

An open-ended question gives the client discretion over the extent of the answer and does not limit the information given, so the client describes the breathing problem in their own words and order. Option a is incorrect because asking about nocturnal awakening is a closed-ended question that belongs later, once the story is out. It pins down one detail while the client's larger account stays uncollected. Option b is incorrect because a leading question supplies the answer inside the question. The client, wanting to cooperate, agrees with the nurse, and any chest pain that exists goes unreported. Option d is incorrect because exertional tolerance answers yes or no. The detail is useful later in the interview, but opening with it means the nurse hears only the items already on the checklist.

Correct Answer: Changing a sterile dressing on a healing incision

Sterile dressing changes fall within the practical nurse's scope for a stable client, while unlicensed assistive personnel do not perform sterile procedures. The registered nurse still assesses and measures the wound and interprets what is found. Option a is incorrect because helping a stable client to the toilet is basic assistance with daily living. Both team members may do it, so it does not separate practical nurse scope from assistive personnel scope. Option c is incorrect because applying anti-embolism stockings appears directly on the list of activities assistive personnel perform. The nurse assesses the legs and circulation first and decides on the stockings, then either worker may apply them. Option d is incorrect because writing down how much of a meal was eaten is simple data recording. Nothing in that step requires a license, and assistive personnel document intake on flow sheets every shift.

Correct Answer: The event described, with findings, notifications and times

The chart carries the event, the assessment done before moving the client, the vital signs, the interventions and the exact times the provider and family were notified. That is the complete clinical account of what happened. Option a is incorrect because naming the report inside the chart drags a protected risk-management document into the clinical record. The event is charted and the report about the event stays on its separate form. Option b is incorrect because assigning blame to a colleague turns the record into evidence against the writer and the institution. A plaintiff's attorney reads that sentence aloud, and it does nothing at all for the client. Option c is incorrect because a one-line summary omits the data that proves an assessment took place. No injury is a conclusion, and without the neurological checks, vital signs and range-of-motion findings behind it, the conclusion is unsupported.

Correct Answer: Looking at the client while the interpreter speaks

The conversation belongs between the nurse and the client. Keeping the eyes on the client and speaking directly preserves that relationship, lets the nurse read facial expression and posture, and keeps the interpreter in a conduit role. Option b is incorrect because summarising invites the interpreter to decide what matters. Interpretation should be sentence by sentence and complete, since the detail an interpreter judges unimportant is often the detail that changes the plan. Option c is incorrect because third person phrasing such as tell them I need to know turns the client into a bystander at the admission. Speak in the first and second person instead. Option d is incorrect because limited English proficiency is not a hearing problem. A raised voice adds nothing to comprehension, embarrasses the client in front of others, and can read as anger across cultures.

Correct Answer: Counting the apical pulse for one full minute

Digoxin requires a full minute apical pulse before administration, because the drug slows the heart rate and an unexpectedly low rate means the dose is held and the prescriber notified. This is the right assessment for this drug. Option a is incorrect because temperature has no bearing on whether a cardiac glycoside is safe to give. Fever monitoring matters for other reasons, but it is not the parameter that governs this particular dose. Option b is incorrect because oxygen saturation guides respiratory therapy and oxygen titration rather than cardiac drug administration. A client in heart failure may need the reading, yet it does not decide whether this tablet is given. Option d is incorrect because a fingerstick glucose is the check that precedes insulin, not a heart medication. Pairing the wrong parameter with the wrong drug is a common source of missed holds on exams and on units.

Correct Answer: Resolved findings persist and errors become unattributable

Copy-forward carries yesterday's findings into today's note, so problems that resolved stay in the record while real changes are missed. Once an error is propagated across several entries, no one can tell which nurse first wrote it. Option a is incorrect because that describes alert fatigue, which arises when a system fires so many warnings that clinicians click past them. No warning is involved in the scenario; text is simply being duplicated. Option c is incorrect because wrong-client entry happens when several charts are open at once and a note is filed under the wrong name. Here the notes reached the right chart; their content is what went wrong. Option d is incorrect because uncritical import of device data is a separate hazard, in which an artifactual monitor reading is accepted without anyone judging whether it is plausible. Lung sounds are charted by a nurse, not a machine.

Correct Answer: Delegation, because the activity extends beyond the role

Delegation transfers an activity that lies outside the delegatee's usual role and basic responsibilities, and it requires additional education plus validated competence. Assignment, by contrast, moves work the person is already authorized to do. Option a is incorrect because assignment describes the first action, giving the nurse four stable clients within her own authorized scope. The activity handed to the assistive personnel sits outside the standard job description, which changes the label. Option b is incorrect because supervision names what comes after the handover, meaning guidance, oversight, follow-up and evaluation. Verifying competence is one of the five rights, not the term for the act of transferring the activity itself. Option c is incorrect because referral sends a client to another discipline, such as physical therapy or a dietitian, for services the nurse does not provide. No outside discipline is involved anywhere in this scenario.

Correct Answer: Contact the pharmacy about an alternative available formulation

Extended-release products are never crushed, because destroying the coating delivers the whole dose at once. The nurse contacts the pharmacy for a liquid or an immediate-release alternative and has the prescription changed rather than altering the tablet. Option b is incorrect because crushing an extended-release tablet destroys the mechanism that spreads the drug over many hours. The client receives a full day's antihypertensive in one swallow, risking a sudden and dangerous drop in pressure. Option c is incorrect because simply omitting an antihypertensive leaves a stroke client's blood pressure uncontrolled. A workable route exists today, so waiting a full shift delays needed treatment without solving the underlying problem. Option d is incorrect because dissolving is only another way of breaking the tablet apart. Warm water disrupts the release coating exactly as crushing does, and thin liquids are also unsafe for someone with a new swallowing impairment.

Correct Answer: Discussing a client's biopsy result in the elevator

An elevator is enclosed and often holds visitors of the very client being discussed, so the conversation is overheard by people with no care relationship. Protected information is protected in spoken form exactly as it is in the chart. Option a is incorrect because printed material carrying client names must be destroyed in a designated bin. That nurse is doing what policy requires, which is why worksheets never leave the unit in a pocket. Option c is incorrect because locking the screen every time you step away is the expected habit, not a lapse. An open session lets anyone passing read the chart and attributes anything typed to the nurse who logged in. Option d is incorrect because angling a display away from public traffic is a recommended safeguard alongside privacy filters. Nothing in that behavior exposes information, so the manager has no reason to correct it.

Correct Answer: Read the order back and spell the name

Telephone orders are written down, read back in full, and confirmed by the prescriber. Spelling out a name with a look-alike partner is the specific safeguard for this pair, and the prescriber confirms before anything is entered. Option a is incorrect because guessing from the diagnosis substitutes the nurse's inference for the prescriber's actual words. Matching a drug to a condition feels logical, yet the prescriber may have intended the sedating agent for a different reason. Option b is incorrect because the pharmacist did not hear the call and can only speculate. Clarification comes from the person who gave the order, and that person is still on the telephone line. Option d is incorrect because verification after the fact protects nobody. Once the wrong agent reaches a client with a rising pressure, the harm is done, and every safeguard in the telephone order sequence exists to work beforehand.

Correct Answer: Recheck the pressure manually with another cuff

A finding that conflicts with the rest of the clinical picture is validated before it is acted on. The client shows no signs of hypotension, so the nurse confirms the reading manually with a correctly sized cuff. Option a is incorrect because reporting an unverified machine reading wastes the surgeon's time and may prompt treatment the client does not need. Verification comes first when the number and the client disagree this plainly. Option b is incorrect because head-down tilt is no longer recommended for hypotension, since it does not durably raise blood pressure and it impairs ventilation. Nothing in this alert client's picture indicates shock anyway. Option c is incorrect because changing an infusion rate requires a prescription and treats a hypovolemia the assessment does not support. Warm dry skin and a clear sensorium argue against the low value being real.

Correct Answer: I would like a fluid bolus and a stat metabolic panel.

The recommendation states specifically what the nurse wants from the provider and by when. A vague call that only reports a finding produces no order and no follow-up, which is the failure the tool was designed to prevent. Option a is incorrect because surgical date and history are background, the clinical context that sets up the current problem. Placing them at the end delays the request the provider is waiting to hear. Option b is incorrect because vital signs and physical findings belong in the assessment, together with the nurse's own conclusion about what is happening. They describe the picture rather than asking for anything. Option d is incorrect because identifying the caller and the client opens the conversation as the situation. Saving that line for the end leaves the provider without a name or a room number while the report is being given.

Correct Answer: Evaluating whether a repositioning plan reduced redness

Evaluation is a step of the nursing process that requires interpreting the client's response and deciding whether the plan works. Assistive personnel may observe and report skin changes, but judging the outcome stays with the nurse. Option b is incorrect because assistive personnel routinely measure and record vital signs for stable clients with predictable courses. The nurse still interprets those numbers, but taking the readings themselves sits inside the assistive personnel role. Option c is incorrect because bathing and hygiene are basic activities of daily living and form the core of the assistive personnel job description. Handing over a shower for a stable client creates no scope problem. Option d is incorrect because recording intake and output is data collection, not analysis. The worker writes down volumes; the nurse later reads the balance and decides what it means for fluid status and treatment.

Correct Answer: The client admitted to the unit

The client is the primary source whenever able to communicate, and this client is alert and oriented. The nurse addresses questions to the client directly and uses the daughter to supplement rather than replace that account. Option a is incorrect because family become the primary source only when the client cannot give a history, as with infants, unconscious adults, or significant cognitive impairment. Eagerness to answer does not transfer that role. Option c is incorrect because the provider contributes through the record and through consultation, which places that information among the secondary sources. Orders describe planned treatment, not the client's own account of the illness. Option d is incorrect because hand-off report passes along another clinician's findings, so it tells the nurse what to look for and then must be verified at the bedside. Report is a secondary source.

Correct Answer: I will repeat the order silently before entering it.

Read-back must be spoken aloud so the prescriber can confirm or correct what the nurse heard. Repeating an order silently verifies nothing, and misheard drug names and doses pass straight through to the client. Option a is incorrect because writing the order down while the provider speaks is the first required step. Memory is unreliable during a phone call, and the read-back is performed from what the nurse wrote. Option b is incorrect because reading the full order back aloud is the safeguard the whole procedure is built around. This statement shows the new nurse already understands the step most often skipped. Option c is incorrect because spelling out look-alike and sound-alike names is standard practice on a phone order. Names that differ by one syllable are the classic source of a wrong-drug event, so the habit is correct.

Correct Answer: Sitting upright in a high Fowler position

Oral medication is given with the client sitting upright, and the client stays up for at least thirty minutes afterward. Upright positioning uses gravity to move the tablet down and lowers the risk of aspiration and esophageal irritation. Option b is incorrect because a client lying flat cannot protect the airway while swallowing a tablet. Turning the head does not replace elevation, and oral medication is never given to someone in that position. Option c is incorrect because the left side-lying Sims position belongs to rectal administration, where it follows the curve of the sigmoid colon. It offers no benefit for a tablet that has to travel down the esophagus. Option d is incorrect because lowering the head works against swallowing entirely. That position is used to promote drainage in other circumstances, and here it would push stomach contents and the tablet toward the airway.

Correct Answer: "I see that this is hard. Tell me more."

Sharing the observation names the cue the nurse has seen and hands the topic back to the client without directing it. Paired with a probe, it gives permission to continue and keeps the disclosure going. Option a is incorrect because a stereotyped reply of that kind tells the client her grief is ordinary. Cliches signal that the nurse is not listening, and the client stops offering anything personal. Option b is incorrect because giving advice substitutes the nurse's judgement for the client's own. A referral may help eventually, yet offering it now ends the exploration before the nurse knows what the client needs. Option c is incorrect because steering back to the medication list dismisses what the client just raised. The task can wait; the moment when a grieving client is willing to speak cannot.