NUR 230 Exam 1

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Sample questions from NUR 230 Exam 1

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

1. 1.A 72-year-old client is admitted to a medical-surgical unit with pneumonia. The client is newly confused, has a respiratory rate of 30/min, oxygen saturation of 86% on room air, and temperature of 38.4 C (101.1 F). Which action should the nurse take first?

   • A.Apply supplemental oxygen and reassess oxygenation
   • B.Obtain a sputum specimen before treatment
   • C.Administer the prescribed antipyretic
   • D.Call the family to establish the client's baseline cognition

   Rationale: Hypoxemia and tachypnea threaten oxygenation, so supplemental oxygen is the immediate priority while the nurse reassesses and escalates care as needed. A sputum specimen and antipyretic may be appropriate but do not correct the immediate threat. Baseline cognition is useful information, but contacting family should not delay treatment of hypoxemia.

2. 2.A 78-year-old client admitted after a fall has an unsteady gait and needs help transferring to the bathroom. The client is alert and has stable vital signs. Which task is appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Assess the client's gait and determine fall risk
   • B.Teach the client how to use a walker
   • C.Assist the client with a previously assessed transfer using a gait belt
   • D.Evaluate whether the pain medication relieved the client's pain

   Rationale: A UAP may assist with routine, predictable care such as a transfer after the RN has assessed the client and established the plan. Assessing gait, teaching walker use, and evaluating medication effectiveness require nursing judgment. The RN remains accountable for assessment, teaching, and evaluation.

3. 3.A 35-year-old client with suspected pulmonary tuberculosis is seen in the emergency department with a persistent cough, night sweats, and weight loss. The client's oxygen saturation is 96% on room air. Which infection-control action is most appropriate?

   • A.Place the client in a negative-pressure room and wear a fit-tested N95 respirator
   • B.Place the client in a private room and wear a surgical mask
   • C.Use contact precautions with a gown and gloves
   • D.Keep the client in a positive-pressure room

   Rationale: Suspected pulmonary tuberculosis requires airborne precautions, including a negative-pressure room and a fit-tested N95 or higher-level respirator. A surgical mask alone does not provide the required protection for staff, and contact precautions are not the primary transmission-based precautions. Positive-pressure rooms protect immunocompromised clients from outside organisms and are inappropriate here.

4. 4.A 64-year-old client with type 2 diabetes is alert and reports shakiness and sweating before lunch. The capillary blood glucose is 58 mg/dL, and the client can swallow safely. Which action should the nurse take?

   • A.Give 15 g of a rapid-acting carbohydrate and recheck glucose in 15 minutes
   • B.Administer the scheduled rapid-acting insulin with the meal tray
   • C.Give a high-fat snack and recheck glucose in 1 hour
   • D.Withhold all food and notify the health care provider

   Answer and rationale are in the full material.

5. 5.A 46-year-old client returns from surgery with a prescription for morphine 2 mg IV every 2 hours as needed for pain. The client rates pain as 8/10, has a respiratory rate of 8/min, and is difficult to arouse. What should the nurse do first?

   • A.Administer the morphine because the pain score is high
   • B.Hold the morphine, stimulate the client, and assess respiratory status
   • C.Ask the client to take deep breaths and administer half the dose
   • D.Give an oral analgesic instead of the prescribed medication

   Answer and rationale are in the full material.