NSG 123

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Sample questions from NSG 123

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

1. 1.On a medical-surgical unit, a 68-year-old client is 1 day postoperative after a hip replacement. The client is alert, has stable vital signs, and needs assistance with morning care. Which task can the RN delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Teach the client how to use the incentive spirometer.
   • B.Evaluate the client's readiness to transfer to a chair.
   • C.Assist the client with bathing and report any new skin redness.
   • D.Assess the client's pain 30 minutes after an analgesic is given.

   Rationale: Assisting with routine bathing is an appropriate UAP task, and the UAP can report unexpected findings for the RN to assess. Pain reassessment, teaching, and evaluation of transfer readiness require nursing judgment and remain the RN's responsibility. Delegate tasks with predictable outcomes and follow up on reported changes.

2. 2.In a community clinic, a 17-year-old client is scheduled for a minor procedure requiring informed consent. The client says, "I do not understand what the procedure involves," and the provider is not yet present. What should the nurse do?

   • A.Ask the client's parent to sign so the procedure can proceed on time.
   • B.Notify the provider that the client needs further explanation before signing.
   • C.Explain the procedure and ask the client to sign the consent form.
   • D.Witness the client's signature and document that questions were answered.

   Rationale: The provider performing the procedure is responsible for explaining its nature, risks, benefits, and alternatives, and the nurse should pause the consent process when the client does not understand. The nurse may clarify information already provided but should not independently explain the procedure or pressure the client to sign. A parent signing does not resolve the client's stated lack of understanding or replace the required provider discussion.

3. 3.Refer to the client's chart. Which actions should the nurse take now for this 11-year-old client in the pediatric emergency department? Select all that apply.

   • A.Notify the provider promptly about the worsening perfusion findings.
   • B.Ask the UAP to determine whether the client is becoming more lethargic.
   • C.Initiate the prescribed isotonic fluid bolus and reassess the client's response.
   • D.Delay escalation until the next scheduled set of vital signs is obtained.
   • E.Repeat the blood pressure and assess capillary refill after the intervention.

   Rationale: The chart shows a rising heart rate, falling blood pressure, delayed capillary refill, and increasing lethargy, so prompt provider notification and the prescribed fluid bolus are indicated. Rechecking blood pressure and perfusion after the intervention evaluates the response to treatment. Waiting for routine vital signs delays care, and assessing mental status for deterioration requires nursing judgment rather than UAP assessment.

4. 4.At change of shift on a telemetry unit, the RN receives report on four clients. Which client should the RN assess first?

   • A.A 63-year-old client who suddenly has slurred speech and right arm weakness that began 10 minutes ago.
   • B.A 45-year-old client with diabetes who has a blood glucose of 68 mg/dL and is awake and requesting juice.
   • C.A 52-year-old client with pneumonia who has a temperature of 38.1 C and is due for an antibiotic.
   • D.A 74-year-old client with heart failure who has gained 1 kg over 2 days and has mild ankle edema.

   Answer and rationale are in the full material.

5. 5.During an outpatient visit, a 29-year-old client asks the nurse to send laboratory results to the client's employer, who called the clinic requesting them. The client has not authorized release. What is the nurse's best action?

   • A.Read the results to the employer over the phone without sending a copy.
   • B.Send only the results related to the client's ability to work.
   • C.Ask the employer to submit the request on official letterhead.
   • D.Explain that written authorization is needed before releasing the results.

   Answer and rationale are in the full material.