NUR 504

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Sample questions from NUR 504

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 9-year-old admitted with pneumonia has an oxygen saturation of 89% on room air, intercostal retractions, and a respiratory rate of 34/min. Three other clients are waiting for care. Which action should the nurse take first?

   • A.Call the provider to request a chest radiograph before taking other action.
   • B.Assess the client's breath sounds and work of breathing while initiating the unit's rapid response process.
   • C.Administer the scheduled oral antibiotic and reassess the oxygen saturation in 30 minutes.
   • D.Ask the unlicensed assistive personnel to obtain a full set of vital signs before intervening.

   Rationale: The low oxygen saturation with retractions and tachypnea signals possible respiratory deterioration, so immediate assessment and escalation take priority. Obtaining vital signs can help but must not delay intervention; a radiograph does not address the immediate threat. The scheduled oral antibiotic may be appropriate later but will not rapidly correct the current respiratory compromise.

2. 2.In the pediatric unit, a 7-year-old who is 18 hours postoperative after an appendectomy becomes increasingly lethargic. The chart shows worsening vital signs and a new elevated lactate. Refer to the client's chart. Which actions should the nurse take now? Select all that apply.

   • A.Administer the prescribed isotonic fluid bolus while monitoring the client's response.
   • B.Activate the rapid response team and communicate the change in perfusion and mental status.
   • C.Obtain the ordered blood cultures before the first antibiotic dose, without delaying treatment.
   • D.Ask the unlicensed assistive personnel to walk the client to improve circulation.
   • E.Administer the prescribed broad-spectrum antibiotic promptly after cultures are collected.

   Rationale: The rising heart rate, falling blood pressure, delayed capillary refill, lethargy, and lactate of 3.8 mmol/L indicate possible septic shock; rapid escalation and the ordered fluid bolus are appropriate. Cultures should be obtained before the first antibiotic when this can be done without delaying treatment, and the prescribed antibiotic should then be administered promptly. Walking is unsafe for a lethargic client with hypotension and would delay resuscitation.

3. 3.During a home visit, a 76-year-old client with heart failure tells the nurse, "I gained 2 kg since yesterday, but I feel fine." The client is alert, has an oxygen saturation of 95% on room air, and has new bilateral ankle edema. Which action is most appropriate?

   • A.Ask the family to arrange a routine appointment in 2 weeks.
   • B.Recommend that the client skip today's diuretic dose to avoid dehydration.
   • C.Instruct the client to drink extra fluids to prevent kidney injury.
   • D.Contact the prescribing clinician promptly to report the rapid weight gain and edema.

   Rationale: A 2-kg gain in one day with new edema suggests fluid retention and warrants prompt reporting, even without subjective dyspnea. Skipping a prescribed diuretic could worsen congestion, while waiting 2 weeks risks progression. Extra fluids are not an appropriate response to possible heart failure exacerbation.

4. 4.A provider prescribes a lumbar puncture for a 16-year-old who is alert, hemodynamically stable, and accompanied by a parent. The adolescent says, "I don't understand why I need this, and I don't want it." Which response by the nurse is best?

   • A.Pause preparation and notify the provider that the adolescent needs further explanation before the procedure.
   • B.Tell the adolescent that refusing the procedure could make the illness worse.
   • C.Explain that the parent has already given permission, so the procedure will proceed as scheduled.
   • D.Ask the parent to explain the procedure and sign the consent form again.

   Answer and rationale are in the full material.

5. 5.On a rehabilitation unit, a 54-year-old client with a stable stroke is prescribed assistance with morning care and ambulation. Which task is appropriate for the registered nurse to delegate to an experienced unlicensed assistive personnel?

   • A.Teach the client how to use a walker on stairs before discharge.
   • B.Determine whether the client's blood pressure medication should be held before therapy.
   • C.Assist the client with a previously assessed transfer using the prescribed gait belt and report any change.
   • D.Evaluate whether the client's new coughing during breakfast indicates aspiration.

   Answer and rationale are in the full material.