Hondros NUR 243 Exam 2

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Sample questions from Hondros NUR 243 Exam 2

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

1. 1.During an evening shift on a medical unit, a 68-year-old client with pneumonia has a respiratory rate of 30/min, SpO2 of 88% on room air, and new confusion. Which action should the RN take first?

   • A.Call the client's family to clarify baseline cognition
   • B.Document the findings and recheck in 30 minutes
   • C.Obtain a sputum specimen before intervening
   • D.Apply oxygen and reassess oxygenation

   Rationale: The hypoxemia and acute confusion indicate impaired oxygenation, so the RN should support breathing immediately and then reassess. Family history and sputum collection may help later but must not delay stabilization. Documentation and delayed reassessment are unsafe when the client is deteriorating.

2. 2.At change of shift on a medical unit, which task is appropriate for the RN to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Measure and report the urine output of a stable client with a Foley catheter
   • B.Teach a client how to use a walker after hip surgery
   • C.Evaluate a client's response to a first dose of IV morphine
   • D.Assess a newly admitted client reporting chest pressure

   Rationale: Measuring and reporting routine urine output for a stable client is within the UAP role, while the RN retains responsibility for interpreting the data. Assessment of chest pressure, teaching, and evaluation after an IV opioid require nursing judgment. The RN should give clear instructions about when to report abnormal output.

3. 3.On a rehabilitation unit, a client with decision-making capacity refuses a recommended blood transfusion for religious reasons. The client's blood pressure is 118/72 mm Hg and there is no active bleeding. What should the nurse do?

   • A.Administer the transfusion because the provider prescribed it
   • B.Ask the family to authorize the transfusion instead
   • C.Respect the refusal, clarify the client's understanding, and notify the provider
   • D.Request that another nurse obtain consent for the transfusion

   Rationale: A capable adult has the right to refuse treatment, and the nurse should confirm understanding, communicate the decision, and support informed choice. Family members cannot override the client's decision-making authority. A prescription does not authorize treatment without consent, and seeking another nurse to obtain consent is inappropriate.

4. 4.Refer to the client's chart. Which findings require the nurse to intervene immediately for this postoperative client? Select all that apply.

   • A.SpO2 decreasing from 96% to 89% on room air
   • B.Increasing restlessness and confusion
   • C.Urine output of 40 mL in the last hour
   • D.Respiratory rate of 10/min after opioid administration
   • E.Incisional pain rated 5/10

   Answer and rationale are in the full material.

5. 5.A charge nurse on a medical unit receives report on four clients. Which client should the nurse assess first?

   • A.A client with diabetes whose premeal glucose is 196 mg/dL and who has no symptoms
   • B.A client with new crushing chest pain, diaphoresis, and blood pressure 92/58 mm Hg
   • C.A client awaiting discharge who needs a prescription clarified
   • D.A client with chronic kidney disease whose potassium is 5.4 mEq/L and unchanged from yesterday

   Answer and rationale are in the full material.