Concepts of Nursing

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Sample questions from Concepts of Nursing

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

1. 1.At change of shift on a medical-surgical unit, a 79-year-old client with pneumonia has an oxygen saturation of 88% on 2 L/min by nasal cannula, while three other clients are waiting for routine medications. Which action should the nurse take first?

   • A.Document the oxygen saturation and reassess in 30 minutes
   • B.Ask the nursing assistant to obtain a repeat temperature
   • C.Assess the client's respiratory status and increase the priority of care
   • D.Administer the routine medications to avoid late doses

   Rationale: An oxygen saturation of 88% despite supplemental oxygen signals impaired oxygenation and requires immediate assessment. Routine medications and a temperature check do not take priority over a potential airway or breathing problem. Documenting without intervening delays needed care.

2. 2.On a medical unit, a 66-year-old client with heart failure is newly confused and more short of breath; SpO2 is 89% on room air and RR is 28/min. Which tasks may the RN delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply.

   • A.Teach the client how to use the prescribed incentive spirometer
   • B.Assess the client's lung sounds and determine whether crackles have increased
   • C.Obtain a repeat set of vital signs and report the results promptly
   • D.Assist the client to sit upright while the RN remains available
   • E.Measure and record the client's urine output

   Rationale: The UAP may collect and report vital signs, assist with basic positioning, and measure and record urine output. Assessing lung sounds and teaching require RN judgment and cannot be delegated. The RN remains responsible for evaluating the change in condition and coordinating care.

3. 3.In an outpatient clinic, a 42-year-old client scheduled for elective surgery says, "I do not understand what the surgeon plans to do." The client has signed the consent form but appears anxious. What should the nurse do?

   • A.Explain the surgical procedure using the consent form
   • B.Notify the surgeon that the client needs more information before consenting
   • C.Ask the client's family to explain the procedure
   • D.Witness the signature and send the client to the operating room

   Rationale: The surgeon performing the procedure is responsible for explaining its nature, risks, benefits, and alternatives. The nurse should pause the process and notify the surgeon when the client has unanswered questions. A family explanation or a witnessed signature does not substitute for informed consent.

4. 4.At 0900 on a pediatric unit, a 7-year-old client with type 1 diabetes is scheduled for a procedure at 1100 and is NPO. The glucose is 68 mg/dL, and the child is alert with no IV access. Which actions should the nurse take? Select all that apply.

   • A.Follow the facility's hypoglycemia protocol, clarifying a safe treatment route with the provider
   • B.Notify the responsible provider promptly about the low glucose and NPO status
   • C.Recheck the blood glucose to confirm the result
   • D.Document the result and wait until after the procedure to report it
   • E.Give the usual oral breakfast without clarifying the NPO order

   Answer and rationale are in the full material.

5. 5.A provider prescribes a medication dose that appears substantially higher than the usual dose for a 3-year-old client in the emergency department. The client weighs 14 kg and is stable. What is the nurse's best action?

   • A.Hold the medication and clarify the dose with the prescriber
   • B.Ask another nurse to calculate the dose and then administer it
   • C.Administer the prescribed dose because the provider entered the order
   • D.Give half the dose and document the adjustment

   Answer and rationale are in the full material.