Nightingale BSN 315

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Sample questions from Nightingale BSN 315

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

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

   • A.A 9-year-old with gastroenteritis who has had two loose stools and is asking for oral fluids
   • B.A 15-year-old with a fractured wrist who reports pain of 7/10 after returning from radiography
   • C.A 7-year-old with asthma who is speaking in full sentences, has an SpO2 of 95% on room air, and is awaiting a scheduled inhaler
   • D.A 12-year-old with a new tracheostomy who has noisy respirations, increasing restlessness, and an SpO2 decrease from 96% to 88%

   Rationale: The client with a new tracheostomy has signs of possible airway obstruction and worsening oxygenation, so immediate assessment and intervention take priority. The child with asthma is currently oxygenating adequately and speaking comfortably, while the client with gastroenteritis and the client with a wrist fracture are not showing immediate threats to life. Prioritize airway and breathing changes over scheduled care, discomfort, or stable gastrointestinal symptoms.

2. 2.During a home visit, a public health nurse finds that a 72-year-old client with heart failure has gained 2.3 kg (5 lb) in 3 days, has new ankle edema, and reports sleeping in a recliner. The client's BP is 148/86 mm Hg, HR 96/min, RR 22/min, and SpO2 93% on room air. Which action should the nurse take first?

   • A.Arrange a routine follow-up visit in 2 weeks
   • B.Teach the client to take an extra dose of the prescribed diuretic today
   • C.Notify the client's health care provider about the weight gain and worsening symptoms
   • D.Recommend that the client reduce fluid intake to 500 mL per day

   Rationale: Rapid weight gain, new edema, and orthopnea suggest worsening heart failure and require prompt communication with the provider for evaluation and treatment direction. Restricting fluids to 500 mL per day or taking an extra diuretic dose without an order could cause harm. A routine appointment in 2 weeks would delay evaluation of a potentially deteriorating condition.

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

   • A.Apply oxygen as indicated by the emergency protocol and reassess oxygenation
   • B.Stay with the client and assess airway, breathing, and circulation
   • C.Ask the nursing assistant to independently evaluate the client's respiratory status
   • D.Activate the rapid response system according to facility policy
   • E.Wait for the next scheduled vital-sign assessment before notifying anyone

   Rationale: The chart shows worsening respiratory distress: the client is increasingly restless, the respiratory rate rises from 24/min to 32/min, and SpO2 falls from 93% to 86% despite supplemental oxygen. Activating rapid response, remaining with the client for an immediate ABC assessment, and applying oxygen under emergency protocol are appropriate. Waiting for routine observations delays care, and the nursing assistant cannot independently assess or manage acute deterioration.

4. 4.A provider prescribes an IV medication for a 34-year-old client. Before administration, the nurse notices that the dose is ten times higher than the dose listed in the medication reference and the client has a documented allergy to that medication. What should the nurse do?

   • A.Administer one tenth of the prescribed dose and document the adjustment
   • B.Hold the medication and clarify the order with the provider
   • C.Give the medication with an antihistamine and monitor for a reaction
   • D.Ask another nurse to administer the medication while the nurse documents the allergy

   Answer and rationale are in the full material.

5. 5.In a long-term care facility, an RN is assigning tasks for a stable 81-year-old resident who needs assistance with morning care. Which task is appropriate to delegate to an experienced nursing assistant?

   • A.Assist the resident with bathing and report any observed skin changes
   • B.Assess the resident's new report of dizziness when standing
   • C.Evaluate whether the resident's antihypertensive medication is effective
   • D.Teach the resident how to use a newly prescribed walker

   Answer and rationale are in the full material.