D455 Hvv 2

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Sample questions from D455 Hvv 2

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

1. 1.At change of shift on a pediatric medical unit, a 6-year-old with sickle cell disease has a temperature of 38.6 C, HR 132, RR 26, BP 94/58, and SpO2 95% on room air. The child reports new chest pain and has a cough. Which action should the nurse take first?

   • A.Ask the unlicensed assistive personnel to obtain another set of vital signs
   • B.Notify the rapid response team and initiate the facility's sepsis or acute chest escalation protocol
   • C.Call the child's parent to obtain consent for a chest radiograph
   • D.Administer the prescribed oral analgesic and reassess the pain in 30 minutes

   Rationale: Fever, new chest pain, cough, tachycardia, and tachypnea in a child with sickle cell disease raise concern for acute chest syndrome and rapid deterioration, so immediate escalation is needed. Analgesia may be appropriate but does not address the time-sensitive respiratory and infectious risk. Repeat vital signs are useful but should not delay escalation, and a parent call is not needed before activating urgent assessment or treatment.

2. 2.In a community clinic, a 17-year-old with type 1 diabetes has a glucose of 52 mg/dL, is awake, and reports shakiness and sweating. The adolescent's parent asks the nurse to discuss the visit. Which action best supports safe care and the adolescent's rights?

   • A.Ask the parent to leave before giving any treatment so confidentiality is maintained
   • B.Tell the parent the glucose result because the parent is responsible for the adolescent's care
   • C.Wait to treat until the adolescent signs a release allowing the nurse to discuss the visit
   • D.Treat the hypoglycemia promptly, then speak privately with the adolescent about what information may be shared with the parent

   Rationale: The nurse should immediately address symptomatic hypoglycemia, then assess the adolescent's preferences and applicable confidentiality rules before sharing protected information. Asking the parent to leave before treatment is unnecessary and could delay care. Automatically sharing the result disregards confidentiality, while delaying treatment for paperwork places the adolescent at avoidable risk.

3. 3.A charge nurse in a long-term care facility is assigning tasks for four residents. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Assess a resident's new confusion and report the likely cause
   • B.Evaluate whether a resident's pain improved after a prescribed analgesic
   • C.Obtain and document the daily weight of a resident with stable heart failure
   • D.Teach a resident with newly diagnosed dysphagia how to use thickened liquids

   Rationale: Obtaining a routine daily weight for a stable resident is a predictable task that can be delegated to a UAP, with the nurse interpreting and following up on the result. Assessing new confusion requires nursing judgment. Teaching and evaluating a response to treatment are also nursing responsibilities and cannot be delegated to the UAP.

4. 4.During a home visit, a 72-year-old taking warfarin for atrial fibrillation reports a fall yesterday and a new headache. The client is alert, with BP 148/86, HR 92, RR 18, and SpO2 97% on room air; the medication list shows warfarin 5 mg daily. Which actions should the nurse take? Select all that apply.

   • A.Advise the client to take an over-the-counter aspirin for the headache
   • B.Notify the prescribing clinician or emergency team that the client takes warfarin
   • C.Document the reported fall, headache onset, and current neurologic status
   • D.Ask the client to avoid driving and remain with another responsible adult while help is arranged
   • E.Arrange immediate emergency evaluation for possible intracranial bleeding
   • F.Ask the client to take the usual warfarin dose while awaiting evaluation

   Answer and rationale are in the full material.

5. 5.A 31-year-old at 32 weeks of pregnancy is admitted to a maternity unit for preeclampsia observation. The client has BP 168/112, a persistent headache, and new blurred vision; fetal heart rate is 140/min. Which action has priority?

   • A.Notify the obstetric clinician immediately and prepare for urgent treatment of severe features
   • B.Ask the client to walk to the bathroom to obtain a clean-catch urine specimen
   • C.Dim the lights and reassess the headache in 1 hour
   • D.Provide written information about warning signs to review before discharge

   Answer and rationale are in the full material.