N480 Weeks 2 Exam West Coast University

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Sample questions from N480 Weeks 2 Exam West Coast University

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, a 72-year-old client admitted with pneumonia has a temperature of 38.1 C, HR 104, RR 24, BP 118/70, and SpO2 91% on 2 L/min oxygen. Which client should the registered nurse assess first?

   • A.A client with pneumonia who is newly confused and has an SpO2 of 91% on 2 L/min oxygen
   • B.A client who reports incisional pain of 7 out of 10 one hour after receiving an analgesic
   • C.A client scheduled for discharge who needs a review of written instructions
   • D.A client with chronic heart failure who gained 0.5 kg overnight and has an SpO2 of 94% on room air

   Rationale: New confusion with hypoxemia may indicate worsening oxygenation and requires immediate assessment. The weight gain is relevant but the client is currently stable, discharge teaching can wait, and pain should be reassessed after the medication but is not the most urgent cue. Prioritize acute changes in breathing and mental status.

2. 2.In a long-term care facility, a 46-year-old registered nurse is assigning care for four residents. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Assess a resident who has new unilateral weakness
   • B.Evaluate whether a resident's pain medication relieved the pain
   • C.Obtain routine vital signs for a stable resident before breakfast
   • D.Teach a resident how to use a newly prescribed inhaler

   Rationale: Obtaining routine vital signs for a stable resident is a predictable task that can be delegated to a trained UAP. Assessing new weakness, teaching inhaler use, and evaluating medication effectiveness require nursing judgment and remain the registered nurse's responsibility. Delegate tasks, not assessment, teaching, or evaluation.

3. 3.Refer to the client's chart. A 63-year-old client is receiving care on a medical-surgical unit. Which actions should the nurse take now? Select all that apply.

   • A.Document the change in status after initiating urgent assessment and response
   • B.Immediately assess the client's airway, breathing, and level of consciousness
   • C.Increase the oxygen flow to 6 L/min without checking the prescription or facility protocol
   • D.Notify the rapid response team according to facility criteria
   • E.Remain with the client while asking another staff member to bring emergency equipment

   Rationale: The chart shows a rapid decline: SpO2 fell from 95% on room air to 86% on 2 L/min, with increasing respiratory rate and new difficulty arousing the client, so immediate ABC assessment and escalation are indicated. Activating the rapid response team and staying with the client while help and equipment are obtained support timely rescue. Document the assessment and actions after addressing the emergency; independently increasing oxygen beyond an order or protocol is not appropriate.

4. 4.During a home visit, a 29-year-old client with limited English proficiency is preparing to sign consent for a scheduled procedure. The client's adult cousin offers to translate the consent discussion. What should the nurse do?

   • A.Ask the cousin to translate because the client chose that family member
   • B.Explain the procedure using gestures and have the cousin confirm the client's agreement
   • C.Ask the client to sign the form and provide an interpreter only if questions arise
   • D.Use a qualified medical interpreter and confirm the client's understanding before witnessing the signature

   Answer and rationale are in the full material.

5. 5.A provider prescribes a medication dose that appears to be ten times the usual dose for a 7-year-old client in the pediatric clinic. The client weighs 24 kg, and the medication is due now. What is the nurse's best action?

   • A.Give one tenth of the prescribed dose and document the change
   • B.Hold the medication and clarify the prescription with the provider
   • C.Ask another nurse to verify the dose and then administer it if they agree
   • D.Administer the dose because the prescription is signed

   Answer and rationale are in the full material.