Health and Healing II

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Sample questions from Health and Healing II

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

1. 1.During a home visit, a 72-year-old client with newly diagnosed heart failure says, "I cannot read the medication labels, so I take the pills by color." The client is alert, has no dyspnea, and has a blood pressure of 128/76 mm Hg and pulse of 78/min. Which action should the nurse take first?

   • A.Give the client a written medication schedule using larger print.
   • B.Tell the client to ask a family member to manage all medications.
   • C.Request that the prescriber simplify the medication regimen.
   • D.Ask the client to demonstrate how the medications are currently organized and taken.

   Rationale: First assess the client's current medication-taking process and ability to manage the regimen; the demonstration can reveal immediate safety risks and what support is needed. A large-print schedule may not help if the client cannot read, and asking family to take over assumes the client wants or needs that arrangement. Simplifying the regimen may be helpful after the nurse establishes the specific barriers and communicates them to the prescriber.

2. 2.At change of shift on a medical-surgical unit, a 46-year-old client with diabetes is due for discharge in 30 minutes. The outgoing nurse reports that the client can describe the insulin dose but has not demonstrated drawing it up. The client is alert, with a blood glucose of 164 mg/dL. Which action should the oncoming nurse take?

   • A.Document that the outgoing nurse provided insulin teaching.
   • B.Ask the client's partner to prepare the insulin at home.
   • C.Delay discharge long enough to observe the client prepare and administer the insulin.
   • D.Give the client a printed insulin handout and proceed with discharge.

   Rationale: Observed return demonstration is needed to verify that the client can safely prepare and administer insulin before discharge. Documentation that teaching occurred does not establish competence, and relying on a partner does not confirm the client's ability or the partner's availability. A handout alone cannot verify this essential psychomotor skill, so discharge should wait until the safety concern is addressed.

3. 3.Refer to the client's chart. Which actions should the nurse take to address the 58-year-old client's worsening condition? Select all that apply.

   • A.Apply oxygen according to the emergency protocol or existing orders and reassess oxygen saturation.
   • B.Stay with the client and reassess respiratory status while help is summoned.
   • C.Ask the client to read the discharge instructions aloud before escalating care.
   • D.Wait for the next scheduled vital-sign check to confirm that the oxygen saturation remains low.
   • E.Immediately notify the rapid response team or activate the facility's emergency response process.

   Rationale: The chart shows rapid deterioration: oxygen saturation falls from 94% to 86% on room air, respiratory rate rises from 20 to 30/min, and the client becomes confused and dyspneic. Activating emergency support, remaining with the client, and supporting oxygenation while reassessing are appropriate immediate actions. Reviewing discharge instructions does not address the acute threat, and waiting for another scheduled check delays care for worsening hypoxemia.

4. 4.A parent of a 5-year-old asks the clinic nurse to explain a new medication label because the parent has difficulty reading English. The child is stable, and the prescription is for an oral antibiotic. Which response best supports safe medication use?

   • A.Arrange a qualified medical interpreter and use a translated, plain-language explanation with teach-back.
   • B.Give the parent the English-language package insert and ask them to review it at home.
   • C.Ask the parent's school-age child to translate the medication instructions.
   • D.Speak more loudly and repeat the label instructions in English.

   Answer and rationale are in the full material.

5. 5.The provider prescribes a high-alert intravenous medication for a 34-year-old client on a telemetry unit. The order specifies a dose in mcg/kg/min, but the client's current weight is not documented. The client is alert, with a heart rate of 84/min and blood pressure of 122/74 mm Hg. What should the nurse do?

   • A.Estimate the client's weight from appearance and calculate the infusion rate.
   • B.Obtain and verify the client's weight, then clarify any incomplete or unclear order before administration.
   • C.Use the weight recorded at the client's last clinic visit six months ago.
   • D.Ask another nurse to independently calculate the dose using an estimated weight.

   Answer and rationale are in the full material.