110-NURSING

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Sample questions from 110-NURSING

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, a 76-year-old client with pneumonia has new confusion, temperature 39.1 C, HR 124/min, RR 30/min, BP 86/48 mm Hg, and SpO2 89% on 2 L/min oxygen. Which action should the nurse take first?

   • A.Ask the client's family about the client's usual mental status
   • B.Obtain a sputum specimen before administering antibiotics
   • C.Document the findings and recheck the blood pressure in 15 minutes
   • D.Activate the rapid response system and support oxygenation

   Rationale: Hypotension, tachycardia, tachypnea, hypoxemia, and acute confusion suggest possible sepsis with impaired perfusion, requiring immediate escalation and support of oxygenation. Collecting a specimen and clarifying baseline status are useful but must not delay stabilization. Waiting and merely documenting risks deterioration.

2. 2.At 0700 on a medical-surgical unit, a 68-year-old client is admitted with fever and suspected sepsis. Refer to the client's chart. Which actions should the nurse take as part of the immediate plan of care? Select all that apply.

   • A.Administer the prescribed broad-spectrum antibiotic promptly
   • B.Wait for the culture results before starting the antibiotic
   • C.Obtain the ordered blood cultures before the first antibiotic dose if this does not delay treatment
   • D.Limit reassessment to once per shift if the temperature falls
   • E.Reassess blood pressure, mental status, and urine output after fluid administration

   Rationale: The chart shows fever, hypotension, elevated lactate, and oliguria, so cultures should be collected promptly, antibiotics given without unnecessary delay, and perfusion reassessed frequently. Waiting for final culture results delays time-sensitive therapy. A falling temperature alone does not establish that perfusion has recovered, so once-per-shift reassessment is inadequate.

3. 3.In a rehabilitation unit, the charge nurse assigns care for four clients. Which assignment is appropriate for a newly licensed RN?

   • A.A client with new-onset chest pain awaiting evaluation
   • B.A stable client receiving a routine IV antibiotic with no history of reaction
   • C.A client with a new tracheostomy who has increasing secretions and stridor
   • D.A client with a fresh postoperative bleed requiring frequent assessment

   Rationale: A stable client receiving a routine medication is an appropriate assignment for a newly licensed RN. Stridor, active bleeding, and new chest pain require immediate assessment and may rapidly become emergencies, making them inappropriate assignments for a novice nurse. The charge nurse should match client acuity and complexity to staff competence.

4. 4.A 54-year-old client scheduled for surgery tells the preoperative nurse, 'I do not understand what the surgeon plans to remove.' The consent form is unsigned. What should the nurse do?

   • A.Ask the client's spouse to explain the procedure
   • B.Explain the procedure using the surgeon's notes and ask the client to sign
   • C.Notify the surgeon that the client needs further explanation before signing
   • D.Witness the signature and document that the client appeared calm

   Answer and rationale are in the full material.

5. 5.During a home visit, a 79-year-old client with heart failure reports a 2.3-kg (5-lb) weight gain in 3 days and worsening orthopnea. The client is alert, with BP 146/82 mm Hg, HR 96/min, RR 24/min, and SpO2 91% on room air. Which action is the priority?

   • A.Notify the prescribing clinician promptly about the worsening congestion
   • B.Encourage the client to drink extra fluid to loosen respiratory secretions
   • C.Teach the client to weigh only once each week
   • D.Schedule a routine follow-up visit for next month

   Answer and rationale are in the full material.