Concept Based Assessment 4

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Sample questions from Concept Based Assessment 4

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

1. 1.At change of shift on a medical-surgical unit, an RN receives report on four clients. Which client should the RN assess first?

   • A.A 30-year-old client awaiting discharge who needs instructions about a new oral antibiotic
   • B.A 72-year-old client with heart failure who has gained 1 kg in 3 days and has bilateral ankle edema
   • C.A 45-year-old client with pancreatitis who reports abdominal pain of 8 on a 0-to-10 scale after receiving analgesia 5 hours ago
   • D.A 68-year-old client with pneumonia who is newly confused, has an SpO2 of 86% on 2 L/min oxygen, and is using accessory muscles

   Rationale: The client with new confusion, hypoxemia, and increased work of breathing has signs of acute respiratory compromise and requires immediate assessment. The client with severe pain needs prompt follow-up, but the available findings do not indicate an immediate threat to airway or breathing. The weight gain and edema require assessment and management, while discharge teaching can wait until urgent needs are addressed. Prioritize unstable clients using airway, breathing, and circulation.

2. 2.In a rehabilitation unit, an RN is planning care for a stable 9-year-old client who needs help with bathing, a routine oral temperature, and reinforcement of previously taught incentive spirometer use. Which task is appropriate to delegate to an unlicensed assistive personnel (UAP)?

   • A.Obtain and record the client's oral temperature
   • B.Teach the client how to use the incentive spirometer
   • C.Evaluate whether the client's breathing improved after spirometer use
   • D.Assess the client's breath sounds before the client uses the incentive spirometer

   Rationale: Obtaining and recording a routine temperature for a stable client is an appropriate delegated task when the UAP is competent and the RN provides appropriate follow-up. Assessing breath sounds and evaluating the response require nursing judgment. Teaching a new skill is also the RN's responsibility; reinforcing an established plan may be delegated only when facility policy and the delegatee's role permit it. The RN remains accountable for delegation and supervision.

3. 3.A 34-year-old client is admitted to an outpatient surgery center for an elective procedure. The client says, "I signed the form, but I still do not understand the major risks." The procedure is scheduled to begin in 20 minutes, and the client has received no sedative. Which actions should the nurse take? Select all that apply.

   • A.Witness the client's signature again to confirm that consent is valid
   • B.Ask the client to describe the procedure's risks and benefits, then answer any questions about those details
   • C.Tell the client that signing the form means the client cannot withdraw consent
   • D.Explain the major procedural risks independently so the procedure can stay on schedule
   • E.Pause preparation for the procedure and notify the surgeon that the client needs further explanation
   • F.Document the client's concern and the notification to the surgeon

   Rationale: The nurse should pause the process and notify the surgeon because the client does not understand the risks, and the procedural provider is responsible for explaining the procedure and answering related questions. Documenting the concern and the notification supports clear communication and continuity of care. Asking the client to explain risks does not replace the provider's explanation, and witnessing a signature does not establish understanding. The nurse should not independently provide the procedural risk discussion or tell the client consent cannot be withdrawn; a competent client may withdraw consent.

4. 4.During a home visit, a public health nurse finds that a 16-year-old client with newly diagnosed type 1 diabetes has no insulin in the home and reports that the caregiver cannot afford the prescription. The client is alert, has a blood glucose of 286 mg/dL, and has no vomiting or deep respirations. Which action is the nurse's priority?

   • A.Document the financial barrier and return for a follow-up visit in 1 week
   • B.Teach the client to reduce carbohydrate intake until the next scheduled appointment
   • C.Arrange an urgent connection with the prescriber and a medication-access resource to obtain insulin
   • D.Advise the client to use a relative's insulin if the insulin type appears similar

   Answer and rationale are in the full material.

5. 5.A provider prescribes IV potassium chloride for a 52-year-old client with a serum potassium of 2.9 mEq/L. The prescription reads, "Potassium chloride 20 mEq IV push now." Which action should the nurse take?

   • A.Administer the prescribed dose slowly through a patent peripheral IV
   • B.Clarify the prescription with the provider before administration
   • C.Ask another RN to verify the dose and then administer it as written
   • D.Dilute the medication in 10 mL of normal saline and administer over 10 minutes

   Answer and rationale are in the full material.