NR341

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Sample questions from NR341

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

1. 1.In the emergency department, a 41-year-old client with type 1 diabetes is being treated for vomiting and dehydration. The client is alert, with glucose 386 mg/dL, potassium 3.1 mEq/L, bicarbonate 16 mEq/L, and moderate serum ketones. Which action should the nurse take first?

   • A.Administer sodium bicarbonate to correct the low bicarbonate level.
   • B.Notify the provider of the potassium result and anticipate potassium replacement before insulin.
   • C.Begin the prescribed regular insulin infusion immediately.
   • D.Recheck the glucose in 1 hour before initiating treatment.

   Rationale: The potassium of 3.1 mEq/L is dangerously low, and insulin can shift potassium into cells, worsening hypokalemia and potentially causing dysrhythmias; the provider should be notified and potassium addressed before insulin. Starting insulin immediately is unsafe until potassium is corrected, even though the client has hyperglycemia and ketones. Bicarbonate is not routinely given for this degree of acidosis, and delaying action for another glucose check does not address the immediate risk.

2. 2.Refer to the client's chart. Which actions should the charge nurse take now to protect the client and manage the medication event? Select all that apply.

   • A.Notify the provider and follow the prescribed monitoring and treatment plan.
   • B.Complete the facility incident report after immediate client needs are addressed.
   • C.Ask the nurse who administered the medication to add the incident report number to the client's chart.
   • D.Assess the client immediately and continue frequent neurologic and vital-sign monitoring.
   • E.Document the client's assessment findings and the medication administered in the health record.

   Rationale: The chart shows that an unintended double dose of warfarin was given and the client's INR increased from 2.6 to 4.8, so immediate assessment, ongoing monitoring, and provider notification are appropriate. The health record should contain objective clinical findings and the medication actually administered, while a separate incident report supports quality and safety review. The incident report number should not be entered in the client's chart because the report is an internal safety document, not part of clinical documentation.

3. 3.During a home visit, a 3-year-old child with a new gastrostomy tube is resting comfortably. The parent asks the visiting nurse to replace the child's feeding-tube dressing while the nurse is present. Which task is appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Determine whether the child is tolerating the prescribed feeding.
   • B.Teach the parent how to secure the tube during bathing.
   • C.Measure and record the child's temperature and report it to the nurse.
   • D.Assess the stoma for new redness, drainage, or tenderness.

   Rationale: Obtaining and reporting a routine temperature for a stable child is within the UAP role when the nurse provides clear directions. Assessing the stoma, teaching the parent, and evaluating feeding tolerance require nursing judgment and remain the nurse's responsibility. A delegated measurement does not transfer responsibility for interpreting the result or responding to abnormal findings.

4. 4.A primigravida at 29 weeks arrives at an outpatient prenatal clinic reporting a severe headache and seeing spots. Her blood pressure is 168/110 mm Hg on repeat measurement, and urine dipstick shows 3+ protein. The clinic's only other nurse is preparing routine teaching for a client with an uncomplicated pregnancy. Which action should the nurse take first?

   • A.Ask the pregnant client to lie on her left side and arrange urgent evaluation for severe preeclampsia.
   • B.Ask the UAP to explain warning signs of preeclampsia while the nurse finishes clinic documentation.
   • C.Recheck the blood pressure in 30 minutes because anxiety can elevate the reading.
   • D.Complete the routine teaching before arranging a transfer so the other client is not delayed.

   Answer and rationale are in the full material.

5. 5.In a community hospital, a 56-year-old client scheduled for elective surgery says, "I signed the form, but I still do not understand the risks." The client received intravenous midazolam 10 minutes ago and is now drowsy but arousable. Which action is most appropriate?

   • A.Ask the client to restate the risks and witness a second signature.
   • B.Ask the client's spouse to confirm the consent on the client's behalf.
   • C.Explain the risks using simpler language and proceed if the client agrees.
   • D.Pause the preparation and notify the surgeon that consent understanding is unresolved and the client is sedated.

   Answer and rationale are in the full material.