Wcu Nurs 201 Final

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Sample questions from Wcu Nurs 201 Final

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

1. 1.A 72-year-old client is admitted to a medical-surgical unit with pneumonia. The client is newly confused, has a temperature of 38.6 C, heart rate of 118/min, respiratory rate of 30/min, blood pressure of 88/54 mm Hg, and oxygen saturation of 91% on room air. Which action should the nurse take first?

   • A.Notify the rapid response team and begin immediate assessment
   • B.Obtain a sputum specimen before starting treatment
   • C.Administer the prescribed antipyretic
   • D.Reorient the client and dim the room lights

   Rationale: Hypotension, tachycardia, tachypnea, fever, and acute confusion suggest possible sepsis with impaired perfusion, requiring immediate escalation and assessment. A sputum specimen and antipyretic may be appropriate but must not delay stabilization. Reorientation alone does not address the client's potentially life-threatening deterioration. The exam takeaway is to prioritize airway, breathing, circulation, and rapid escalation when a client is unstable.

2. 2.A 46-year-old client on a medical-surgical unit is scheduled to receive several medications. The client reports an allergy to penicillin, and the medication record includes a newly prescribed antibiotic. Which action should the nurse take before administering the medication?

   • A.Check the allergy details and verify the prescribed antibiotic with the prescriber or pharmacist
   • B.Administer the antibiotic with food to reduce the chance of a reaction
   • C.Ask the client whether the medication looks familiar
   • D.Hold all medications until the client's family can confirm the allergy

   Rationale: The nurse should clarify the reaction history and determine whether the prescribed drug poses a cross-sensitivity risk before administration. Giving it with food does not prevent an allergic reaction. A client's recognition of a medication is not a safe substitute for verification, and waiting for family unnecessarily delays unrelated medications. The takeaway is to resolve an allergy concern using reliable clinical information before giving a potentially related drug.

3. 3.A 78-year-old client with a history of falls is admitted from home. The client is alert, uses a cane, and has stable vital signs. Which intervention is most appropriate to reduce fall risk?

   • A.Keep the bed low, place the call light within reach, and assist with ambulation
   • B.Apply a vest restraint while the client is in bed
   • C.Keep all four side rails raised to prevent the client from getting up
   • D.Ask the client to remain in bed unless a family member is present

   Rationale: A low bed, accessible call light, and assisted mobility reduce risk while supporting independence. A restraint is not justified for a stable client and can cause injury or worsen agitation. Four raised side rails can function as a restraint and may increase injury risk if the client climbs over them. The exam takeaway is to use individualized, least-restrictive fall-prevention measures.

4. 4.A 63-year-old client is receiving oxygen at 2 L/min by nasal cannula in a hospital room. The client asks to light a cigarette. Which response should the nurse make?

   • A.Explain that smoking is prohibited because oxygen supports combustion, and offer help with nicotine cravings
   • B.Turn off the oxygen briefly so the client can smoke safely
   • C.Allow smoking if the client moves away from the oxygen equipment
   • D.Ask the client to smoke near an open window

   Answer and rationale are in the full material.

5. 5.A 54-year-old client with suspected Clostridioides difficile infection is admitted to a medical unit with frequent watery stools and a temperature of 38.1 C. Which action is most important for the nurse to take after providing care?

   • A.Wash hands with soap and water
   • B.Use alcohol-based hand rub as the only hand hygiene method
   • C.Place used linens in an open container outside the room
   • D.Wear an N95 respirator when entering the room

   Answer and rationale are in the full material.