14 Days Free Trial

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Sample questions from 14 Days Free Trial

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

1. 1.During morning rounds in the medical unit, a 72-year-old client's condition changes. Refer to the client's chart. Which action should the nurse take first?

   • A.Activate the rapid response team.
   • B.Review the client's discharge support system.
   • C.Administer the prescribed oral antipyretic.
   • D.Obtain a clean-catch urine specimen.

   Rationale: New confusion, a BP of 84/48 mm Hg, tachypnea, and declining oxygen saturation indicate acute deterioration requiring immediate emergency support. Urine collection may help identify the infection source but must not delay stabilization. An antipyretic does not correct impaired perfusion, and discharge planning is inappropriate during instability. Prioritize rescue when infection is accompanied by signs of organ hypoperfusion.

2. 2.On a rehabilitation unit, a 68-year-old client recovering from a hip replacement has stable vital signs and an established mobility plan. Which task is appropriate for the RN to delegate to trained assistive personnel?

   • A.Assess new calf tenderness reported during ambulation.
   • B.Assist the client to the bathroom using the prescribed walker.
   • C.Evaluate whether the walker height is appropriate.
   • D.Teach the client how to avoid hip dislocation.

   Rationale: Assisting a stable client with established mobility activities is appropriate for trained assistive personnel. Evaluating walker fit and assessing new calf tenderness require nursing judgment. Initial teaching about dislocation prevention remains the RN's responsibility. Delegate predictable tasks, not assessment, teaching, or evaluation.

3. 3.In the preoperative holding area, a 46-year-old client scheduled for a hysterectomy says, 'I signed the form, but I still do not understand whether there are other treatments.' After confirming stable vital signs, which action should the nurse take?

   • A.Explain the surgical alternatives and obtain a new signature.
   • B.Ask the client's spouse to confirm the decision.
   • C.Administer the prescribed sedative to reduce anxiety.
   • D.Notify the surgeon and pause preparation until the questions are addressed.

   Rationale: The surgeon must clarify treatment alternatives so the client's consent is informed and voluntary. The nurse may reinforce information but should not substitute for the provider's disclosure of procedural alternatives. A spouse cannot authorize treatment for a capable adult, and sedation could impair decision-making. A signed form alone does not establish informed consent.

4. 4.Before discharge from the hospital, a 79-year-old client newly prescribed apixaban for atrial fibrillation reports living alone, using ibuprofen for arthritis, and sometimes forgetting medications. Hemoglobin is 13.2 g/dL and creatinine is 0.9 mg/dL. Which actions should the nurse include in discharge coordination? Select all that apply.

   • A.Arrange routine INR testing to adjust the apixaban dose.
   • B.Use teach-back to verify understanding of bleeding precautions.
   • C.Request pharmacist review of prescription and nonprescription medications.
   • D.Instruct the client to stop apixaban whenever bruising occurs.
   • E.Collaborate on an adherence plan that matches the client's abilities.

   Answer and rationale are in the full material.

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

   • A.A 76-year-old with heart failure who gained 0.5 kg over 24 hours without dyspnea.
   • B.A 54-year-old with pneumonia whose SpO2 is 94% on prescribed oxygen and unchanged from baseline.
   • C.A 61-year-old who had a thyroidectomy 4 hours ago and now reports neck tightness and difficulty breathing.
   • D.A 32-year-old awaiting discharge who needs instructions about oral iron.

   Answer and rationale are in the full material.