Mcphs 404 Exam 3

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Sample questions from Mcphs 404 Exam 3

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 heart failure has increasing dyspnea and new confusion. Refer to the client's chart. Which actions should the nurse take first? Select all that apply.

   • A.Obtain a complete dietary history before intervening.
   • B.Ask an assistive personnel to ambulate the client to assess tolerance.
   • C.Raise the head of the bed and apply oxygen as prescribed by protocol.
   • D.Notify the rapid response team of the acute change.
   • E.Stay with the client and reassess oxygenation and work of breathing.

   Rationale: Elevating the head of the bed and supporting oxygenation address the client's acute respiratory distress; the falling SpO2 and worsening work of breathing support rapid escalation. Staying with the client permits continuous reassessment while help arrives. A dietary history is not the immediate priority, and ambulation could worsen instability.

2. 2.At change of shift on a medical unit, a 45-year-old client with a new tracheostomy has thick secretions and a weak cough. Which task is appropriate for the registered nurse to delegate to experienced assistive personnel?

   • A.Assess the client's breath sounds before suctioning.
   • B.Suction the tracheostomy using sterile technique.
   • C.Measure and record the client's oxygen saturation and report a value below the prescribed limit.
   • D.Teach the client how to use a communication board.

   Rationale: Measuring and reporting oxygen saturation is a predictable data-collection task that can be delegated to trained assistive personnel. Assessment, sterile tracheostomy suctioning, and teaching require registered-nurse judgment or skill. The nurse remains responsible for evaluating reported findings and responding to changes.

3. 3.During a home health visit, a 72-year-old client with diabetes says, "I cannot afford all these medicines." The client has skipped insulin twice this week; blood glucose is 286 mg/dL. Which action should the nurse take first?

   • A.Instruct the client to borrow insulin from a neighbor.
   • B.Ask the client to describe the specific cost and access barriers.
   • C.Tell the client to stop taking insulin until finances improve.
   • D.Document nonadherence and end the visit.

   Rationale: Exploring the client's specific barriers is the first step toward a safe, individualized plan and referral to available resources. Stopping insulin without a plan risks harm, and borrowing another person's medication is unsafe. Documentation alone does not address the immediate obstacle or support continuity of care.

4. 4.A provider prescribes a blood transfusion for a 31-year-old client with symptomatic anemia. Which action is essential immediately before the transfusion begins?

   • A.Compare the client's identification band with the blood product at the bedside with a qualified second verifier.
   • B.Ask assistive personnel to verify the blood product with the nurse.
   • C.Administer the blood through the same tubing as intravenous antibiotics.
   • D.Prime the tubing with dextrose 5% in water.

   Answer and rationale are in the full material.

5. 5.In a pediatric clinic, a 9-year-old with asthma is prescribed a daily inhaled corticosteroid and a rescue inhaler. Which statement by the parent indicates correct understanding?

   • A.We will stop the controller medicine once symptoms improve for one day.
   • B.We will use the rescue inhaler on a fixed schedule even when the child has no symptoms.
   • C.We will use the corticosteroid only when wheezing starts.
   • D.We will have the child rinse the mouth after using the corticosteroid.

   Answer and rationale are in the full material.