BSN 225

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Sample questions from BSN 225

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

1. 1.A 72-year-old client admitted to a medical unit with pneumonia has a temperature of 38.4 C (101.1 F), a respiratory rate of 28/min, and an oxygen saturation of 89% on room air. The nurse receives report on four clients. Which client should the nurse assess first?

   • A.A client scheduled for discharge who needs help arranging transportation
   • B.The client with pneumonia and an oxygen saturation of 89%
   • C.A client with chronic arthritis reporting pain of 7 on a 0-to-10 scale
   • D.A client with diabetes whose premeal glucose is 218 mg/dL

   Rationale: The client with pneumonia has impaired oxygenation and tachypnea, requiring immediate assessment and intervention. The client with arthritis needs pain management, and the glucose value requires follow-up, but neither finding indicates the same immediate threat to life. Transportation planning can wait until urgent clinical needs are addressed. Prioritize airway and breathing concerns over stable needs.

2. 2.A 74-year-old client on a surgical unit is scheduled for a procedure requiring informed consent. The client says, "I don't understand what the surgeon plans to do," and appears anxious. Which actions should the nurse take? Select all that apply.

   • A.Continue to support the client's right to delay signing until questions are answered
   • B.Notify the surgeon that the client needs further explanation
   • C.Assess whether the client has questions or needs an interpreter
   • D.Provide the procedure's risks and alternatives as if the nurse were the surgeon
   • E.Ask the client to sign the form so the procedure is not delayed

   Rationale: The surgeon or other procedural provider must explain the procedure, risks, benefits, and alternatives, so the nurse should notify the surgeon and support the client's informed decision. The nurse can assess communication needs and arrange an interpreter when appropriate. The nurse should not pressure the client to sign or independently provide the provider's full consent discussion.

3. 3.A 59-year-old client admitted to a medical unit has a new prescription for an anticoagulant. During medication reconciliation, the client reports taking an over-the-counter herbal supplement but cannot recall its name. What should the nurse do next?

   • A.Ask the client to identify the supplement and notify the prescriber or pharmacist before administration
   • B.Tell the client to stop all prescribed medications until the supplement is identified
   • C.Administer the anticoagulant because prescribed medications take priority
   • D.Document the supplement as harmless because it is sold without a prescription

   Rationale: The nurse should clarify the supplement and seek pharmacist or prescriber review because some supplements increase bleeding risk or interact with anticoagulants. Administering without checking could expose the client to a preventable adverse effect. The client should not be told to stop prescribed therapy without an authorized plan, and nonprescription products are not automatically harmless. Medication reconciliation includes supplements and over-the-counter products.

4. 4.A 46-year-old client in a rehabilitation unit has a new prescription for an opioid analgesic after orthopedic surgery. The client's respiratory rate is 10/min and the client is difficult to arouse. Which action should the nurse take?

   • A.Give the medication and reassess the client in 1 hour
   • B.Administer the opioid with food to reduce nausea
   • C.Hold the opioid and promptly assess respiratory status and notify the prescriber
   • D.Encourage the client to ambulate before receiving the medication

   Answer and rationale are in the full material.

5. 5.A 55-year-old client on a medical unit has a new prescription for a medication that requires monitoring of serum potassium. Before administering the first dose, the nurse notes a potassium level of 3.0 mEq/L and an irregular pulse. What should the nurse do?

   • A.Ask the client to drink orange juice and then give the medication
   • B.Administer the medication and recheck potassium tomorrow
   • C.Document the findings as expected and continue the medication
   • D.Hold the medication and notify the prescriber of the findings

   Answer and rationale are in the full material.