NUR 211 Excelsior University

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Sample questions from NUR 211 Excelsior University

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, four clients need assessment. Which client should the RN assess first?

   • A.A 63-year-old with osteoarthritis reporting chronic knee pain rated 6/10
   • B.A 46-year-old awaiting discharge who needs instructions about oral antibiotics
   • C.A 72-year-old with pneumonia whose SpO2 decreased from 95% to 88% on oxygen at 2 L/min
   • D.A 28-year-old scheduled for surgery who has questions about the consent form

   Rationale: The client with pneumonia has worsening oxygenation despite supplemental oxygen and requires immediate assessment. Discharge teaching and clarification of consent are important but can wait while an acute breathing problem is addressed. Chronic knee pain requires intervention but is less urgent than deteriorating oxygenation. Prioritize acute changes that threaten airway, breathing, or circulation.

2. 2.On a rehabilitation unit, an RN coordinates care for a stable 79-year-old recovering from a hip fracture. The client has already been assessed and can walk with a walker and one-person assistance. Which task is appropriate to delegate to experienced assistive personnel?

   • A.Determine whether the client's gait has improved
   • B.Assist the client to the bathroom using the established mobility plan
   • C.Evaluate whether the prescribed analgesic improved activity tolerance
   • D.Teach the client how to climb stairs with the walker

   Rationale: Assisting a stable client with an established mobility plan is a predictable task appropriate for assistive personnel. Determining gait improvement and evaluating medication effectiveness require nursing assessment and judgment. Initial teaching about stairs must be performed by a licensed nurse or appropriate rehabilitation professional. Delegation transfers a task, not the RN's responsibility for assessment and evaluation.

3. 3.During morning rounds in a long-term care facility, the RN reviews an 84-year-old resident's condition. Refer to the client's chart. Which actions should the RN take now? Select all that apply.

   • A.Perform a focused respiratory and perfusion assessment
   • B.Wait for the routine afternoon provider visit before reporting the findings
   • C.Activate the facility's urgent response process and arrange emergency evaluation
   • D.Ask assistive personnel to determine whether the resident has sepsis
   • E.Report the recent assessment and vital-sign trends using SBAR

   Rationale: New confusion, respirations of 28 breaths/min, SpO2 of 89%, and BP of 88/50 mm Hg indicate acute deterioration requiring focused RN assessment and urgent emergency evaluation. SBAR communication should include the decline from the 0700 baseline and the new fever and leukocytosis. Determining the cause of deterioration requires licensed clinical judgment and cannot be delegated to assistive personnel. Waiting for afternoon rounds would dangerously delay treatment of possible sepsis and shock.

4. 4.Before elective surgery in an ambulatory center, a 52-year-old client states, 'I signed the form, but I do not understand why removing the entire thyroid is necessary.' No sedative has been administered. What is the RN's best action?

   • A.Notify the surgeon and pause preparation until the client's questions are addressed
   • B.Explain the surgical risks and ask the client to confirm consent
   • C.Continue preparation because the signed form establishes informed consent
   • D.Ask the client's spouse to authorize the procedure

   Answer and rationale are in the full material.

5. 5.In a cardiac clinic, a 68-year-old client taking warfarin reports starting an over-the-counter aspirin tablet each day after seeing an advertisement. The client denies bleeding, and the INR is 2.6. Which action is most appropriate?

   • A.Document the aspirin as safe because the INR is therapeutic
   • B.Recommend replacing warfarin with aspirin
   • C.Tell the client to halve the warfarin dose until the next visit
   • D.Reconcile all medications and contact the prescriber to clarify whether aspirin is indicated

   Answer and rationale are in the full material.