Health and Healing IV Test 2 Durham College

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Sample questions from Health and Healing IV Test 2 Durham College

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 68-year-old client admitted with pneumonia has an oxygen saturation of 88% on 2 L/min by nasal cannula, increased work of breathing, and new confusion. Which action should the charge nurse take first?

   • A.Ask the unlicensed assistive personnel to obtain another set of vital signs in 30 minutes.
   • B.Delegate administration of a prescribed as-needed sedative to the practical nurse.
   • C.Call the provider to request a chest radiograph before intervening.
   • D.Assess the client immediately and initiate appropriate oxygenation measures.

   Rationale: The decreased oxygen saturation, respiratory distress, and acute confusion indicate possible worsening hypoxemia, so the charge nurse should assess and support the client immediately. Waiting for another set of vital signs delays care, and obtaining imaging is not the first response to an unstable client. A sedative could further impair respiratory status and is not an appropriate delegated response.

2. 2.In a long-term care facility, an 82-year-old resident with stable osteoarthritis needs help with morning hygiene and has scheduled oral medications. Which task is appropriate for the registered nurse to delegate to an unlicensed assistive personnel?

   • A.Assist the resident with bathing and report any new skin changes.
   • B.Assess the resident's pain after the morning medication.
   • C.Teach the resident how to use a newly prescribed walker.
   • D.Determine whether the resident's medication is controlling the pain.

   Rationale: Bathing is a routine activity of daily living that can be delegated, with instructions to report unexpected findings such as skin changes. Pain assessment and evaluation of medication effectiveness require nursing judgment. Teaching a resident to use a newly prescribed walker also requires assessment and individualized instruction by a licensed nurse.

3. 3.In the emergency department, a 16-year-old client with a forearm injury has increasing pain and swelling after a cast was applied 2 hours ago. The client reports numbness in the fingers; capillary refill is 4 seconds. Which actions should the nurse take? Select all that apply.

   • A.Apply a heating pad over the cast to improve circulation.
   • B.Elevate the arm above the level of the heart and reassess in 2 hours.
   • C.Assess and document distal pulses, sensation, movement, color, and temperature.
   • D.Notify the provider promptly about the neurovascular changes.
   • E.Loosen external bandages if present and permitted by protocol while urgently escalating care.

   Rationale: Increasing pain, numbness, and delayed capillary refill can indicate impaired perfusion or compartment syndrome, so a focused neurovascular assessment and prompt escalation are essential. Loosening an external bandage may reduce constriction when allowed by protocol, but it does not replace urgent evaluation. Delaying reassessment is unsafe, and heat can worsen swelling and is not appropriate over the cast.

4. 4.A client states, "I do not understand this surgery, and I do not want to sign the consent form yet." The 45-year-old client is alert and scheduled for an elective procedure in 90 minutes. What is the nurse's best action?

   • A.Ask the family to sign the consent form on the client's behalf.
   • B.Pause the signing process and notify the surgeon that the client needs more information.
   • C.Explain the surgical risks and benefits so the client can sign on time.
   • D.Witness the client's signature and document that the questions were answered.

   Answer and rationale are in the full material.

5. 5.During a home visit, a 74-year-old client with heart failure says, "I took my water pill twice this morning because my ankles were swollen." The client is alert, reports no dizziness, and has a blood pressure of 118/72 mm Hg. Which action should the nurse take first?

   • A.Document the report and discuss it at the next scheduled home visit.
   • B.Instruct the client to skip all medications for the remainder of the day.
   • C.Assess the medication name, dose, timing, symptoms, and recent fluid intake.
   • D.Tell the client to drink several liters of water to replace the diuretic effect.

   Answer and rationale are in the full material.