Exam 4 NUR103

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Sample questions from Exam 4 NUR103

This material has 75 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, the charge nurse receives report on four clients. Which client should the charge nurse assess first?

   • A.A 46-year-old with diabetes whose blood glucose is 248 mg/dL before breakfast and who has no symptoms
   • B.A 73-year-old with a urinary tract infection whose temperature is 38.2 C and who is due for acetaminophen
   • C.A 54-year-old 6 hours after thyroidectomy who is restless and has a new high-pitched sound on inspiration
   • D.A 68-year-old with heart failure who gained 1 kg in 24 hours and has new crackles halfway up both lung fields

   Rationale: The new inspiratory sound and restlessness after thyroidectomy suggest evolving airway obstruction from laryngeal edema or hematoma, so immediate assessment and intervention are needed. The heart failure findings require prompt follow-up, but the client is not showing the same immediate airway threat. The fever and elevated glucose need care but are less urgent in the absence of instability. Prioritize a potentially compromised airway over other important but less immediately life-threatening findings.

2. 2.During a home visit, a 9-year-old with cystic fibrosis is preparing for discharge from a short hospital stay. The parent reports difficulty coordinating treatments with school and work. Which tasks may the registered nurse delegate to an experienced unlicensed assistive personnel (UAP) under an established plan of care? Select all that apply.

   • A.Reinforce the already-taught schedule for routine airway-clearance sessions
   • B.Report the child's measured temperature and oxygen saturation to the registered nurse
   • C.Teach the parent how to adjust pancreatic enzyme doses when meals vary
   • D.Obtain and document the child's weight using the same scale used during the previous visit
   • E.Assess the child's work of breathing and determine whether it has worsened
   • F.Evaluate whether the current home-care plan is meeting the family's needs

   Rationale: Obtaining a routine weight and reporting measured findings such as temperature and oxygen saturation are predictable data-gathering tasks that may be delegated when the UAP is trained and the nurse provides oversight. Assessing respiratory status and evaluating the plan require nursing judgment and remain the registered nurse's responsibility. Reinforcing a complex treatment schedule in this context could be interpreted as teaching or require individualized evaluation, so the nurse should handle it. Adjusting enzyme doses is medication teaching and clinical decision-making, not a UAP task.

3. 3.A 17-year-old is scheduled for an elective procedure at an outpatient clinic. The client says, "I signed the form, but I do not understand what the surgeon plans to do." The client's parent is waiting outside. What is the nurse's best action?

   • A.Ask the parent to explain the procedure and then continue the preoperative checklist
   • B.Pause preparation and notify the surgeon that the client needs further explanation before consent is confirmed
   • C.Document that the client signed the consent and proceed because the parent is available
   • D.Explain the procedure using the consent form and ask the client to sign again

   Rationale: The client's statement indicates that informed understanding may be lacking, so the nurse should pause preparation and contact the provider responsible for explaining the procedure. A parent cannot substitute for the required provider explanation, and the nurse should not provide the procedural explanation in place of the surgeon. Re-signing the form does not establish understanding. The exam takeaway is to advocate for a valid informed-consent process rather than treating the signature as sufficient by itself.

4. 4.A provider prescribes digoxin for an 81-year-old admitted with heart failure. Before the morning dose, the client's apical pulse is 54/min, the client reports nausea, and the laboratory report shows a digoxin level of 2.4 ng/mL (therapeutic range 0.5-2.0 ng/mL). Which action should the nurse take?

   • A.Hold the dose and notify the provider of the findings
   • B.Ask the UAP to recheck the pulse after the client walks
   • C.Administer the dose with food and reassess the pulse in 1 hour
   • D.Give the dose and request a repeat digoxin level with the next routine blood draw

   Answer and rationale are in the full material.

5. 5.Refer to the client's chart. Which actions should the nurse take now for the 42-year-old client? Select all that apply.

   • A.Stop the transfusion and keep the intravenous line open with normal saline using new tubing
   • B.Increase the transfusion rate to finish the unit before the next vital-sign check
   • C.Notify the provider and blood bank of the suspected transfusion reaction
   • D.Send the blood bag and tubing to the blood bank according to policy
   • E.Administer the next prescribed unit after the client's temperature returns to baseline
   • F.Document the client's symptoms, vital signs, interventions, and notifications

   Answer and rationale are in the full material.