Mcphs

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Sample questions from Mcphs

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 charge nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 41-year-old client reporting incisional pain of 7 on a 0-to-10 scale 1 hour after analgesia
   • B.A 68-year-old client with pneumonia whose oxygen saturation decreased from 94% to 88% on 2 L/min by nasal cannula
   • C.A 52-year-old client with diabetes whose blood glucose is 240 mg/dL before breakfast
   • D.A 74-year-old client awaiting discharge whose ride has arrived

   Rationale: The client with pneumonia has worsening hypoxemia despite supplemental oxygen and needs immediate respiratory assessment and intervention. The elevated glucose requires follow-up, but the client is not described as acutely unstable. The discharge ride and uncontrolled pain need timely attention but are lower priority than impaired oxygenation. Prioritize an acute threat to breathing over other care needs.

2. 2.In a long-term care facility, a 79-year-old resident with mild dementia is prescribed a new oral medication. The resident refuses it and says, "I do not want that pill." Which action should the nurse take?

   • A.Document the refusal and omit further assessment of the resident's decision
   • B.Ask another staff member to administer the medication later without discussing it
   • C.Ask about the resident's concerns, explain the medication, and respect the refusal
   • D.Crush the medication into applesauce without telling the resident

   Rationale: The nurse should assess the reason for refusal, provide understandable information, and respect the resident's right to decline treatment. Covert administration violates autonomy and may be unsafe if the medication cannot be crushed. Asking another staff member to administer it without addressing the refusal does not resolve the concern. Documentation is needed, but it does not replace assessment and communication.

3. 3.Refer to the client's chart. After reviewing the morning findings, which actions should the nurse take first to coordinate care for this 15-year-old client with a possible transfusion reaction? Select all that apply.

   • A.Obtain the prescribed blood and urine specimens for the reaction workup
   • B.Send the blood bag and tubing to the blood bank according to facility policy
   • C.Notify the provider and blood bank promptly
   • D.Stop the transfusion and keep the intravenous line open with normal saline using new tubing
   • E.Restart the transfusion at a slower rate after giving an antipyretic

   Rationale: The temperature increase from 37.0 C to 38.2 C, new chills, and flank discomfort during transfusion require stopping the blood and maintaining access with normal saline and new tubing. The provider and blood bank must be notified, and the blood bag and tubing should be returned according to policy. Collecting the prescribed specimens supports investigation of the reaction. Restarting the transfusion, even more slowly and after an antipyretic, is unsafe until the reaction is evaluated.

4. 4.A home health nurse visits a 73-year-old client who has heart failure and takes digoxin and furosemide. The client reports nausea and seeing yellow halos; the apical pulse is 52/min, and potassium is 3.0 mEq/L. Which action should the nurse take?

   • A.Have the client take an extra dose of furosemide to reduce fluid retention
   • B.Encourage a low-potassium diet and schedule a routine follow-up visit
   • C.Instruct the client to take the digoxin with food and recheck the pulse tomorrow
   • D.Withhold the digoxin and contact the provider promptly

   Answer and rationale are in the full material.

5. 5.The parent of a 4-year-old asks how to prevent medication errors when giving a prescribed liquid antibiotic at home. Which instruction is most important?

   • A.Measure each dose with an oral syringe and follow the prescribed amount
   • B.Stop the antibiotic when the child's fever resolves
   • C.Double the next dose if a dose is missed
   • D.Use a kitchen teaspoon because it is convenient

   Answer and rationale are in the full material.