Community RETAKE1

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Sample questions from Community RETAKE1

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 72-year-old client with pneumonia has new confusion, temperature 39.1 C, HR 124/min, RR 30/min, BP 86/50 mm Hg, and SpO2 89% on room air. Which action should the nurse take first?

   • A.Activate the rapid response system and support oxygenation
   • B.Ask the family about the client's usual mental status
   • C.Obtain a sputum specimen before intervening
   • D.Administer the scheduled antipyretic

   Rationale: Hypotension, tachycardia, tachypnea, hypoxemia, and acute confusion suggest rapidly worsening sepsis with impaired perfusion. Activating rapid response and addressing oxygenation take priority over obtaining a specimen or giving an antipyretic. Baseline history is useful but should not delay stabilization.

2. 2.During a home visit, a 68-year-old client with heart failure reports worsening breathlessness. Refer to the client's chart. Which actions should the nurse take now? Select all that apply.

   • A.Place the client upright to ease breathing
   • B.Reconcile the medication list, including nonprescription drugs
   • C.Encourage the client to drink several large glasses of water
   • D.Document the findings and defer follow-up until the next scheduled visit
   • E.Notify the provider promptly about the worsening symptoms and weight gain

   Rationale: The chart shows rapid weight gain, crackles, and worsening dyspnea, which require prompt escalation and positioning to support breathing. Medication reconciliation can identify missed doses or drugs that worsen fluid retention. Extra fluid may worsen congestion, and waiting until a routine visit is unsafe.

3. 3.At change of shift in a rehabilitation unit, a 57-year-old client with a new tracheostomy has thick secretions and an ineffective cough. Which task may the registered nurse delegate to experienced assistive personnel?

   • A.Teach the client how to use a speaking valve
   • B.Measure and report oxygen saturation and respiratory rate
   • C.Change the tracheostomy ties
   • D.Assess whether suctioning is indicated

   Rationale: Assistive personnel may collect and report routine measurements for a stable client when directed. Determining the need for suctioning requires nursing assessment, and changing ties or teaching involves skilled nursing judgment. The RN remains responsible for interpreting the findings and intervening.

4. 4.In a public health clinic, a 24-year-old client with newly diagnosed HIV asks whether the diagnosis must be reported. Which response is most appropriate?

   • A.Advise the client to avoid treatment until deciding whom to tell
   • B.Tell the client that the diagnosis is shared with the client's employer
   • C.Explain that HIV is reportable to public health authorities, with information protected under applicable confidentiality rules
   • D.Promise that no information can be shared with any agency

   Answer and rationale are in the full material.

5. 5.In an outpatient clinic, a 45-year-old client taking warfarin reports black, tarry stools and dizziness. BP is 94/60 mm Hg and HR is 116/min. Which action is the priority?

   • A.Advise the client to skip one dose and recheck the INR next week
   • B.Recommend an iron supplement and increased fluids
   • C.Schedule a routine appointment for the next available clinic day
   • D.Arrange emergency evaluation and notify the provider immediately

   Answer and rationale are in the full material.