NUR 185 Hondros College of Nursing

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Sample questions from NUR 185 Hondros College of Nursing

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

1. 1.In the emergency department, a 68-year-old client with pneumonia has a temperature of 39.1 C, HR 124/min, RR 30/min, BP 86/48 mm Hg, and SpO2 89% on room air. At 0800, the client was alert; at 0830, the client is confused and has cool extremities. Which action should the nurse take first?

   • A.Obtain a sputum specimen before administering treatment
   • B.Administer the prescribed acetaminophen
   • C.Activate the rapid response system and initiate sepsis interventions
   • D.Teach the client about the importance of completing antibiotics

   Rationale: The falling blood pressure, tachycardia, hypoxemia, and new confusion indicate possible septic shock and require immediate escalation and resuscitative care. Obtaining a specimen and treating fever are secondary to stabilizing perfusion and oxygenation. Antibiotic teaching is inappropriate during acute deterioration.

2. 2.On a medical unit, a 72-year-old client with heart failure is admitted with worsening dyspnea. At 0800, the client had SpO2 94% on 2 L/min nasal cannula and mild ankle edema; at 1000, the client is more breathless and has new crackles. Refer to the client's chart. Which actions should the nurse take? Select all that apply.

   • A.Encourage the client to drink 1 L of water
   • B.Lay the client flat to conserve energy
   • C.Assess respiratory effort and oxygenation promptly
   • D.Place the client in high-Fowler position
   • E.Notify the provider of the acute change

   Rationale: High-Fowler positioning can improve ventilation, and prompt respiratory assessment helps determine severity. New crackles and worsening dyspnea warrant timely provider notification. Additional fluid may worsen congestion, while a flat position can make breathing more difficult.

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

   • A.A 2-hour postoperative client with new stridor and restlessness
   • B.A client with chronic back pain requesting the prescribed analgesic
   • C.A client with diabetes whose premeal glucose is 198 mg/dL
   • D.A client awaiting discharge who needs instructions about a dressing change

   Rationale: New stridor can indicate airway obstruction and requires immediate assessment and intervention. Pain, discharge teaching, and a moderately elevated glucose are important but do not take priority over an emerging airway threat. The exam priority is to address airway compromise first.

4. 4.On a medical unit, a 64-year-old client with heart failure receives furosemide 40 mg IV. Two hours later, the client reports dizziness when standing; potassium is 3.1 mEq/L and BP changes from 126/74 mm Hg supine to 94/58 mm Hg standing. Refer to the client's chart. Which action is the priority?

   • A.Encourage the client to walk to improve circulation
   • B.Restrict potassium-containing foods
   • C.Administer the next dose of furosemide early
   • D.Assist the client to lie down and implement fall precautions

   Answer and rationale are in the full material.

5. 5.On a medical unit, a 61-year-old client receiving chemotherapy has an oral temperature of 38.4 C and an absolute neutrophil count of 400/mm3. The client reports chills that began 30 minutes ago. Refer to the client's chart. Which actions should the nurse take? Select all that apply.

   • A.Administer a rectal suppository for fever
   • B.Notify the provider immediately about possible neutropenic fever
   • C.Use appropriate hand hygiene and protective measures
   • D.Obtain ordered cultures promptly before antimicrobial therapy when feasible
   • E.Place fresh flowers in the room to improve mood

   Answer and rationale are in the full material.