Need 5 Gold Test

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Sample questions from Need 5 Gold Test

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

1. 1.A 68-year-old client on a medical unit reports sudden shortness of breath and chest pressure. The client is restless, has a heart rate of 124/min, respiratory rate of 30/min, blood pressure of 88/54 mm Hg, and oxygen saturation of 86% on room air. Which action should the nurse take first?

   • A.Apply supplemental oxygen and activate the rapid response team
   • B.Obtain a complete medication history
   • C.Assist the client to ambulate to the bathroom
   • D.Recheck the oxygen saturation in 30 minutes

   Rationale: The client has acute respiratory distress and hemodynamic instability, so oxygen support and immediate escalation are priorities. A medication history is useful but delays treatment; ambulation increases oxygen demand, and waiting to recheck the saturation risks deterioration. The exam takeaway is to address immediate threats to airway, breathing, and circulation first.

2. 2.A 74-year-old client with a new stroke is admitted to a neurologic unit. The client has right facial droop, slurred speech, and coughing when offered water; vital signs are stable. Which action is most appropriate before giving oral medication?

   • A.Crush the medication and mix it with applesauce
   • B.Perform or obtain a prescribed swallowing screen
   • C.Give the medication with a straw
   • D.Place the client supine and give the medication slowly

   Rationale: Coughing with water and facial weakness suggest dysphagia and aspiration risk, so swallowing safety must be assessed before oral intake. Crushing medication may alter its release, a straw can increase aspiration risk, and the supine position is unsafe for swallowing. The exam takeaway is to withhold oral intake until swallowing safety is established after stroke.

3. 3.A 45-year-old client arrives at the emergency department with fever, productive cough, and suspected pulmonary tuberculosis. The temperature is 38.4 C (101.1 F), and the client is hemodynamically stable. Which infection-control action should the nurse take?

   • A.Place the client in a negative-pressure room and wear a fit-tested respirator
   • B.Place the client in a positive-pressure room and wear a surgical mask
   • C.Use contact precautions and a gown and gloves only
   • D.Keep the client in a shared room until the sputum result is available

   Rationale: Suspected pulmonary tuberculosis requires airborne precautions, including a negative-pressure room and a fit-tested respirator. Positive-pressure rooms protect immunocompromised clients, contact precautions alone do not prevent airborne spread, and a shared room creates unnecessary exposure. The exam takeaway is to initiate isolation based on suspected transmission risk rather than waiting for confirmation.

4. 4.A 32-year-old client with type 1 diabetes is receiving IV insulin for diabetic ketoacidosis in the intensive care unit. The glucose is 238 mg/dL, potassium is 3.1 mEq/L, and the client has a regular heart rate of 104/min. Which action should the nurse take?

   • A.Continue the insulin infusion and recheck potassium in 4 hours
   • B.Pause the insulin infusion and notify the provider about the low potassium
   • C.Administer sodium bicarbonate immediately
   • D.Give a rapid-acting insulin injection subcutaneously

   Answer and rationale are in the full material.

5. 5.A 79-year-old client on a surgical unit is 1 day postoperative after hip repair. The client suddenly becomes confused and attempts to climb out of bed; oxygen saturation is 89%, respiratory rate is 24/min, and the client is afebrile. What should the nurse do first?

   • A.Apply oxygen and assess respiratory status
   • B.Apply wrist restraints to prevent a fall
   • C.Administer the prescribed PRN sedative
   • D.Document the behavior and reassess at the end of the shift

   Answer and rationale are in the full material.