Critical Thinking of a Register Nurse 200 for Hondros College of Nursing

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Sample questions from Critical Thinking of a Register Nurse 200 for Hondros College 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, the nurse receives report on four clients. Which client should the nurse assess first?

   • A.A client 6 hours after thyroidectomy who is restless and has noisy, high-pitched respirations
   • B.A client with diabetes whose premeal glucose is 248 mg/dL and who requests prescribed insulin
   • C.A client with a urinary tract infection whose temperature is 38.1 C and who reports urinary frequency
   • D.A client with chronic heart failure who has gained 1 kg in 24 hours and has bilateral ankle edema

   Rationale: Noisy, high-pitched respirations and restlessness after thyroid surgery suggest airway obstruction, which can progress rapidly and requires immediate assessment and intervention. The heart failure findings need assessment but do not indicate the same immediate threat to life. The elevated glucose and fever require timely follow-up, but neither takes priority over a threatened airway. Use airway, breathing, circulation and acute change to guide prioritization.

2. 2.In an emergency department, a 24-year-old client with a deep forearm laceration is alert and has stable vital signs. Which task can the registered nurse delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Teach the client how to change the dressing at home
   • B.Evaluate whether the analgesic relieved the client's pain
   • C.Assess the wound for tendon injury and document the findings
   • D.Obtain and record the client's vital signs while the registered nurse prepares the client for suturing

   Rationale: Obtaining routine vital signs for a stable client is an appropriate delegated task when the UAP has the necessary competence and the registered nurse provides follow-up. Wound assessment, teaching, and evaluation of a medication response require nursing judgment and remain the registered nurse's responsibility. The nurse should clarify reporting parameters, such as a change in blood pressure or level of consciousness. Delegation transfers a task, not accountability for the client's care.

3. 3.During orientation on a pediatric unit, a 7-year-old is admitted with dehydration after vomiting. The registered nurse is assigning tasks to a licensed practical nurse (LPN) and a UAP. Which tasks are appropriate to delegate to the UAP? Select all that apply.

   • A.Assess the child's mucous membranes and report the findings
   • B.Teach the parent how to prepare an oral rehydration solution
   • C.Transport a labeled urine specimen to the laboratory
   • D.Measure and record urine output from the collection hat
   • E.Obtain the child's weight using the same scale used at admission

   Rationale: Obtaining a weight, measuring and recording urine output, and transporting a properly labeled specimen are routine tasks that may be delegated to a competent UAP. Assessing mucous membranes requires nursing assessment and interpretation, so it is not delegated. Teaching the parent requires nursing judgment and evaluation of learning. The registered nurse remains responsible for communicating expectations and evaluating reported data.

4. 4.A provider prescribes a medication dose that is four times the dose listed in the facility's reference for a 3-year-old. The child is stable, and the medication is due now. What should the nurse do first?

   • A.Ask another nurse to administer the dose instead
   • B.Hold the medication and clarify the prescription with the prescribing provider
   • C.Administer the prescribed dose because the provider is responsible for prescribing
   • D.Give one quarter of the prescribed dose and document the change

   Answer and rationale are in the full material.

5. 5.During a home health visit, a 79-year-old client with heart failure says, "I cannot afford all these pills, so I skip the water pill some days." The client's weight is up 2.3 kg (5 lb) from the previous week, and the client has mild ankle edema. Which response is best?

   • A.Document nonadherence and wait to discuss it at the next scheduled visit
   • B.Tell the client that skipping medication is irresponsible and must stop
   • C.Ask the client to describe medication costs and collaborate on contacting the prescriber or pharmacist about affordable options
   • D.Instruct the client to double the next dose of the diuretic

   Answer and rationale are in the full material.