hEALTH and Healing II NUR 4506 Test 2

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Sample questions from hEALTH and Healing II NUR 4506 Test 2

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

1. 1.At change of shift in a medical-surgical unit, the charge nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 54-year-old client 6 hours after abdominal surgery who is newly restless, has a heart rate of 128/min, and has a blood pressure of 86/50 mm Hg
   • B.A 73-year-old client with heart failure who has bilateral ankle edema and is scheduled for a diuretic at 0900
   • C.A 42-year-old client with pancreatitis reporting pain of 8 on a 0-to-10 scale who received analgesia 30 minutes ago
   • D.A 68-year-old client with chronic obstructive pulmonary disease whose oxygen saturation is 90% on the prescribed 2 L/min by nasal cannula

   Rationale: The postoperative client's new restlessness, tachycardia, and hypotension suggest acute deterioration, such as hemorrhage, and require immediate assessment and intervention. The oxygen saturation may be within the prescribed target for the client with chronic obstructive pulmonary disease. The client with pancreatitis needs reassessment of pain, and the client with edema needs follow-up, but neither has the same signs of circulatory instability.

2. 2.During a home visit, a 79-year-old client with limited mobility says, "I cannot get to the pharmacy to pick up my new heart medication." The client has no medication doses remaining and reports no chest pain or shortness of breath. Which action should the community health nurse take first?

   • A.Ask the client to take half of the previous medication dose until transportation is available
   • B.Tell the client to wait until the next scheduled clinic appointment to discuss the problem
   • C.Ask a neighbor to purchase the medication and leave it outside the client's home
   • D.Assess the client's medication access and contact the prescriber and pharmacy to arrange a safe, timely supply

   Rationale: The nurse should address the immediate barrier to prescribed treatment by coordinating with the prescriber and pharmacy and assessing what options are safe and available. Changing a dose without an order is unsafe, and delaying the issue could interrupt essential treatment. A neighbor should not be asked to obtain or handle medication without the client's consent and appropriate arrangements.

3. 3.Refer to the client's chart. Which actions should the nurse take now? Select all that apply.

   • A.Ask the client to stand to assess whether dizziness occurs with position changes
   • B.Prepare for possible fluid resuscitation and obtain access to the prescribed emergency resources
   • C.Activate the rapid response system for the acute change in status
   • D.Notify the surgeon of the new hypotension, tachycardia, and increasing abdominal distention
   • E.Give the prescribed oral analgesic before completing further assessment
   • F.Maintain the client in bed and assess airway, breathing, circulation, and the surgical dressing

   Rationale: The client's blood pressure has fallen from 118/72 to 84/48 mm Hg while the heart rate has risen from 92 to 132/min, with new restlessness and increasing abdominal distention; these changes may indicate hemorrhage and warrant a rapid response. Keep the client in bed, rapidly assess ABCs and the dressing, notify the surgeon, and prepare for ordered emergency treatment. Standing the client could worsen instability, and an oral analgesic is not the priority during suspected acute deterioration.

4. 4.In a rehabilitation facility, a 36-year-old client with a stable spinal cord injury has a routine urinary catheter change due at 1000. Which task is appropriate for the registered nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Teach the client how to prevent catheter-associated infection
   • B.Measure and record the client's oral intake and urinary output
   • C.Assess the client for signs of a urinary tract infection
   • D.Change the indwelling urinary catheter using sterile technique

   Answer and rationale are in the full material.

5. 5.A client states, "I understand the procedure, but I do not want surgery today." In a preoperative holding area, a 47-year-old client is scheduled for a nonemergency operation and has already signed the consent form. What should the nurse do?

   • A.Administer the prescribed sedative so the client can proceed without further distress
   • B.Tell the client that signing the form means the client cannot change their mind
   • C.Ask the client to explain the reason for refusing and continue preparing the client while the surgeon is notified
   • D.Ask the client's family to persuade the client to undergo the operation

   Answer and rationale are in the full material.