Nurs 125

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Sample questions from Nurs 125

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, the RN receives report on four clients. Which client should the RN assess first?

   • A.A 54-year-old client 6 hours after abdominal surgery who reports new shortness of breath and has an SpO2 of 88% on room air
   • B.A 68-year-old client with chronic heart failure who has 2+ ankle edema and is awaiting a scheduled diuretic
   • C.A 42-year-old client with diabetes whose premeal blood glucose is 238 mg/dL and who has no symptoms
   • D.A 79-year-old client with a urinary catheter who has cloudy urine and a temperature of 37.6 C

   Rationale: The postoperative client has new respiratory distress and hypoxemia, requiring immediate assessment and intervention to support airway and breathing. The edema, elevated glucose without symptoms, and cloudy urine with only a low-grade temperature are important but do not take priority over acute hypoxemia. Use airway, breathing, circulation and changes from baseline to prioritize clients.

2. 2.In a long-term care facility, an RN is planning assignments for a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which task is appropriate for the RN to delegate to the UAP?

   • A.Teach a resident with heart failure how to follow a low-sodium diet
   • B.Evaluate whether a newly prescribed analgesic relieved a resident's pain
   • C.Assess a resident who has new confusion and a temperature of 38.3 C
   • D.Obtain and document the morning weight of a stable resident with heart failure

   Rationale: Obtaining a routine weight for a stable resident is a predictable task that can be delegated to a trained UAP, with the RN responsible for interpreting the result. Assessing new confusion, teaching, and evaluating a medication response require nursing judgment and cannot be delegated to UAP. The RN should provide clear instructions about when and how to report the weight.

3. 3.During a community health clinic visit, the parent of a 4-year-old asks how to prepare the child for a scheduled procedure requiring moderate sedation. Which actions should the nurse take to promote safety and informed decision-making? Select all that apply.

   • A.Verify that the parent or legal guardian has received an explanation of the procedure and has provided consent
   • B.Tell the parent that signing the consent form means the nurse has explained all procedural risks
   • C.Ask the parent to remain silent during preparation so the child will not become anxious
   • D.Confirm the child's allergies, current medications, and last oral intake according to the sedation protocol
   • E.Ensure that age-appropriate monitoring and emergency equipment are available before sedation begins

   Rationale: The nurse verifies that consent has been obtained by the authorized decision-maker and confirms safety information, including allergies, medications, and last oral intake. The nurse also checks that appropriate monitoring and emergency equipment are ready before sedation. The provider performing the procedure is responsible for explaining its risks and benefits, and supporting the parent's calm, age-appropriate involvement can help the child cope.

4. 4.A provider prescribes a medication for a 73-year-old client who reports a severe penicillin allergy. The electronic record lists an antibiotic in the same drug class as the allergy. Which action should the nurse take?

   • A.Ask the UAP to verify the allergy with the client before administration
   • B.Administer the medication with food and observe the client for a reaction
   • C.Hold the medication and contact the provider to clarify the prescription
   • D.Give the medication and document the allergy in the client's discharge instructions

   Answer and rationale are in the full material.

5. 5.Refer to the client's chart. Which actions should the nurse take now for the client on the postoperative unit? Select all that apply.

   • A.Apply oxygen as prescribed or per emergency protocol and reassess oxygen saturation
   • B.Encourage the client to ambulate in the hallway before reassessing
   • C.Activate the rapid response system because respiratory status is worsening
   • D.Document the findings at the end of the shift if the oxygen saturation improves
   • E.Stay with the client and promptly notify the provider of the change in condition

   Answer and rationale are in the full material.