NUR 108

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Sample questions from NUR 108

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 76-year-old client with heart failure who has new confusion and an oxygen saturation of 88% on room air
   • B.A 54-year-old client with diabetes who has a blood glucose of 242 mg/dL before breakfast
   • C.A 68-year-old client awaiting discharge instructions after an uncomplicated procedure
   • D.A 39-year-old client reporting incisional pain of 7 out of 10 one hour after surgery

   Rationale: New confusion with hypoxemia may indicate impaired oxygenation and requires immediate assessment and intervention. Hyperglycemia, pain, and discharge preparation need attention but are not as urgent as a possible acute respiratory problem. Prioritize threats to airway, breathing, and circulation.

2. 2.In a community hospital, an RN is assigning care for four clients to a practical nurse and an experienced assistive personnel. Which tasks are appropriate to delegate? Select all that apply.

   • A.Ask assistive personnel to obtain routine vital signs on a stable client awaiting discharge
   • B.Ask the practical nurse to reinforce previously taught colostomy care with a stable client
   • C.Ask the practical nurse to administer scheduled oral medications to a stable client
   • D.Ask assistive personnel to feed a client who has a new facial droop and possible stroke
   • E.Ask the practical nurse to perform the initial assessment of a client admitted with chest pain

   Rationale: The practical nurse may reinforce established teaching and administer routine medications to stable clients, while assistive personnel may collect routine vital signs. Initial assessment requires RN judgment, and feeding a client with a possible new stroke is unsafe until swallowing ability is evaluated. Delegate predictable tasks, not assessment or care requiring clinical judgment.

3. 3.A client's potassium is 6.2 mEq/L (reference range 3.5 to 5.0 mEq/L) on a telemetry unit. The client reports muscle weakness, and the monitor shows peaked T waves. Which action should the nurse take first?

   • A.Document the finding and recheck the level with morning laboratory work
   • B.Notify the provider and prepare for urgent treatment while maintaining cardiac monitoring
   • C.Ask assistive personnel to ambulate the client in the hallway
   • D.Encourage the client to eat a potassium-rich snack

   Rationale: Hyperkalemia with peaked T waves and weakness can progress to a life-threatening dysrhythmia, so urgent provider notification and continuous monitoring are indicated. Potassium-rich food could worsen the abnormality, and delaying reassessment is unsafe. Ambulation does not address the immediate cardiac risk.

4. 4.Refer to the client's chart. Which actions should the nurse take now for this client on a medical-surgical unit? Select all that apply.

   • A.Administer the next scheduled antihypertensive without reviewing the current orders
   • B.Reassess the client's status and vital signs while preparing to escalate care
   • C.Notify the provider promptly about the worsening blood pressure and urine output
   • D.Place the client on continuous cardiac monitoring
   • E.Encourage oral fluids and wait an hour before reporting the change

   Answer and rationale are in the full material.

5. 5.In an outpatient clinic, a client with limited English proficiency arrives for consent before a procedure. The client's adult child offers to translate the consent discussion. Which action is best?

   • A.Ask another client in the waiting room to interpret
   • B.Ask the adult child to translate because the child knows the client's history
   • C.Have the client sign the form and explain the procedure afterward
   • D.Arrange for a qualified medical interpreter to assist with communication

   Answer and rationale are in the full material.