Mcphs 404 Exam

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Sample questions from Mcphs 404 Exam

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

1. 1.At 0900 on a medical-surgical unit, a 72-year-old client admitted with pneumonia becomes more confused and short of breath. Refer to the client's chart. Which actions should the nurse take now? Select all that apply.

   • A.Apply oxygen as prescribed and position the client upright.
   • B.Ask the unlicensed assistive personnel to assess the client's lung sounds.
   • C.Wait 30 minutes and repeat the assessment before notifying anyone.
   • D.Reassess respiratory status and oxygen saturation.
   • E.Notify the rapid response team about the acute deterioration.

   Rationale: The oxygen saturation has fallen from 94% to 86% and the respiratory rate has risen to 30/min, with new confusion; oxygen, immediate escalation, and focused reassessment are appropriate. Waiting delays treatment of acute hypoxemia, and lung-sound assessment requires licensed nursing judgment. The exam takeaway is to respond to a worsening trend, not merely a single abnormal value.

2. 2.During a clinic visit, a 58-year-old client with diabetes reports dizziness after taking the morning medications without eating. The client is alert, diaphoretic, and has a blood glucose of 54 mg/dL. What should the nurse do first?

   • A.Notify the health care provider before intervening.
   • B.Give 15 g of fast-acting oral carbohydrate.
   • C.Give a high-protein snack and recheck glucose in 1 hour.
   • D.Administer the scheduled rapid-acting insulin.

   Rationale: The client is alert and can swallow, so 15 g of fast-acting carbohydrate is an appropriate immediate treatment for symptomatic hypoglycemia. Insulin would worsen the low glucose, and delaying treatment to call the provider is unsafe. A high-protein snack does not correct hypoglycemia as rapidly as a simple carbohydrate.

3. 3.At change of shift on a medical unit, the charge nurse assigns care for four clients. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Teach a client how to use an incentive spirometer.
   • B.Assess a client reporting new chest pressure.
   • C.Evaluate the response to a newly administered analgesic.
   • D.Obtain a routine morning weight for a stable client with heart failure.

   Rationale: Obtaining a routine weight for a stable client is a predictable task that can be delegated to trained UAP. Chest-pressure assessment, teaching, and evaluation of medication response require nursing judgment. The RN remains responsible for interpreting and acting on delegated findings.

4. 4.In the emergency department, a 24-year-old client with a possible ectopic pregnancy reports sudden severe abdominal pain. The client is pale; BP is 84/50 mm Hg, HR 132/min, and the abdomen is rigid. Which action has priority?

   • A.Establish large-bore intravenous access and alert the emergency team.
   • B.Provide a warm blanket and reassess pain in 30 minutes.
   • C.Obtain a urine specimen for pregnancy testing.
   • D.Ask the client to describe the location of the pain.

   Answer and rationale are in the full material.

5. 5.On a rehabilitation unit, a 79-year-old client with a new stroke has right-sided weakness and coughs while drinking water. Which actions should the nurse take to reduce aspiration risk? Select all that apply.

   • A.Place food on the weak side of the mouth.
   • B.Position the client upright for any oral intake once cleared.
   • C.Request a speech-language pathology swallow evaluation.
   • D.Keep the client NPO until a swallow evaluation is completed.
   • E.Offer thin liquids through a straw to make swallowing easier.

   Answer and rationale are in the full material.