NUR1068C

Free preview · Original latest version

Sample questions from NUR1068C

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

1. 1.At change of shift on a medical unit, a 76-year-old client with pneumonia has an oxygen saturation of 88% on 2 L/min by nasal cannula, respiratory rate 30/min, and new confusion. Which action should the nurse take first?

   • A.Review the latest chest radiograph before intervening
   • B.Call the client's family to establish the client's baseline cognition
   • C.Assess airway and breathing, then increase oxygen per protocol and summon assistance
   • D.Ask the unlicensed assistive personnel to recheck the oxygen saturation in 30 minutes

   Rationale: New hypoxemia, tachypnea, and confusion indicate possible respiratory deterioration, so immediate assessment and support of oxygenation take priority. Waiting for imaging or a later recheck delays care. The family may provide useful baseline information, but that is not the first action; a change this acute should not be delegated.

2. 2.In an outpatient clinic, a 52-year-old client with diabetes reports dizziness and sweating before lunch. The client's glucose is 58 mg/dL, and the client is alert and able to swallow. Which action is most appropriate?

   • A.Administer the scheduled insulin and provide lunch afterward
   • B.Give a high-fat snack and recheck the glucose in 1 hour
   • C.Call emergency medical services before treating the low glucose
   • D.Give 15 g of a fast-acting carbohydrate and recheck glucose in 15 minutes

   Rationale: An alert client with hypoglycemia should receive 15 g of fast-acting carbohydrate, followed by a glucose recheck in 15 minutes. Insulin would worsen the hypoglycemia, and fat slows carbohydrate absorption. Emergency services are not the first step when the client can safely take oral treatment.

3. 3.Refer to the client's chart. Which actions should the nurse take now for this client with suspected sepsis? Select all that apply.

   • A.Reassess perfusion and vital signs frequently while initiating ordered fluids
   • B.Obtain the ordered blood cultures before the first antibiotic dose if this will not delay treatment
   • C.Administer the prescribed broad-spectrum antibiotic promptly after cultures are obtained
   • D.Wait for the culture results before starting antimicrobial therapy
   • E.Notify the rapid response team or provider of the acute deterioration

   Rationale: The client's rising temperature and heart rate, falling blood pressure, and delayed capillary refill suggest worsening infection with impaired perfusion; escalation, cultures, prompt antibiotics, and close reassessment are appropriate. Cultures should be obtained before antibiotics when this does not cause a harmful delay. Waiting for culture results postpones time-sensitive treatment.

4. 4.During a home health visit, a 79-year-old client with heart failure says, "I have gained 2.3 kg (5 lb) since Monday." The client has new ankle edema and mild shortness of breath when walking. Which response is best?

   • A.Recommend stopping the prescribed diuretic until the next appointment
   • B.Contact the prescribing clinician promptly to report the weight gain and symptoms
   • C.Reassure the client that daily weight changes are expected with heart failure
   • D.Advise the client to drink extra water to protect kidney function

   Answer and rationale are in the full material.

5. 5.On a surgical unit, a registered nurse is assigning care for four clients. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Ambulate a stable postoperative client who has already been assessed and cleared to walk
   • B.Assess a newly admitted client reporting chest pressure
   • C.Evaluate whether a PRN analgesic relieved a client's pain
   • D.Teach a client how to use an incentive spirometer

   Answer and rationale are in the full material.