NUR 245

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Sample questions from NUR 245

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

1. 1.During an emergency department reassessment of a 24-year-old client, the RN identifies a change in condition. Refer to the client's chart. Which action has the highest priority?

   • A.Repeat the blood pressure in 30 minutes.
   • B.Initiate rapid escalation for suspected septic shock.
   • C.Administer the prescribed antipyretic.
   • D.Obtain a detailed dietary history.

   Rationale: The fall in BP to 82/46 mm Hg, new confusion, and lactate of 4.6 mmol/L indicate severe hypoperfusion requiring immediate escalation and resuscitation. An antipyretic addresses fever but not circulatory failure. Dietary assessment and waiting 30 minutes would delay time-sensitive care. Prioritize deteriorating perfusion over symptom management.

2. 2.On a rehabilitation unit, a 67-year-old client recovering from a hip replacement is stable and has an established transfer plan. Which task may the RN delegate to trained unlicensed assistive personnel (UAP)?

   • A.Determine whether new calf tenderness indicates a complication.
   • B.Teach the client how to use a walker.
   • C.Evaluate whether pain medication improved mobility.
   • D.Assist the client to a chair using the prescribed transfer technique.

   Rationale: Assisting a stable client with an established transfer technique is a routine task appropriate for trained UAP. New calf tenderness requires RN assessment, and initial walker teaching requires licensed nursing judgment. Evaluating the response to medication is also the RN's responsibility. Delegate predictable tasks, not assessment, teaching, or evaluation.

3. 3.Before surgery, a 45-year-old client in the preoperative unit says, 'I signed the consent, but I still do not understand why I need this operation.' The client has not received sedation. What should the RN do?

   • A.Notify the surgeon and delay preparation that would interfere with informed consent.
   • B.Explain the surgical risks and ask the client to sign again.
   • C.Continue preparation because the consent form is signed.
   • D.Ask the spouse to confirm the client's consent.

   Rationale: The surgeon must clarify the procedure, risks, benefits, and alternatives when the client does not understand. The RN advocates for informed decision-making rather than independently supplying the surgeon's procedural explanation. A spouse cannot replace a capable client's consent, and a signature alone does not establish understanding. Unresolved consent concerns must be addressed before sedation or surgery.

4. 4.At a primary care clinic, a 32-year-old client with decision-making capacity refuses a recommended blood transfusion for chronic anemia after discussing the risks and alternatives. Hemoglobin is 7.4 g/dL, BP is 118/72 mm Hg, and HR is 86 beats/min. Which response best protects the client's rights?

   • A.Request an emergency court order before the client leaves.
   • B.Tell the client treatment is mandatory at this hemoglobin level.
   • C.Document the informed refusal and collaborate on acceptable alternatives.
   • D.Ask a family member to authorize the transfusion.

   Answer and rationale are in the full material.

5. 5.While reviewing anticoagulation therapy for a 58-year-old hospitalized client, the RN identifies several concerns. Refer to the client's chart. Which actions should the RN take now? Select all that apply.

   • A.Anticipate a prescription for a non-heparin anticoagulant.
   • B.Notify the provider immediately about suspected heparin-induced thrombocytopenia.
   • C.Massage the painful calf to improve venous return.
   • D.Administer the scheduled heparin line flush.
   • E.Stop the heparin infusion.

   Answer and rationale are in the full material.