BSN 246

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Sample questions from BSN 246

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, a 76-year-old client admitted with pneumonia has T 38.2 C, HR 112, RR 28, BP 88/54, and SpO2 89% on 2 L/min nasal cannula. Which action should the nurse take first?

   • A.Ask the nursing assistant to repeat the vital signs
   • B.Increase oxygen to 4 L/min and reassess in 30 minutes
   • C.Obtain a sputum specimen before notifying the provider
   • D.Activate the rapid response team and remain with the client

   Rationale: Hypotension, tachycardia, tachypnea, and hypoxemia indicate acute deterioration requiring immediate escalation. Increasing oxygen alone or waiting for another assessment delays needed intervention, and obtaining a specimen is not the priority. The nursing assistant may obtain routine measurements but must not be asked to manage this unstable client.

2. 2.In a rehabilitation unit, a 69-year-old client with a new stroke has right-sided weakness and difficulty swallowing. The RN is planning care with an experienced practical nurse and an assistive personnel. Which tasks are appropriate to delegate? Select all that apply.

   • A.Ask the assistive personnel to assess the client's ability to swallow water
   • B.Ask the practical nurse to reinforce previously taught transfer instructions
   • C.Ask the practical nurse to perform the initial neurologic assessment
   • D.Ask the assistive personnel to record intake and output for the stable client
   • E.Ask the practical nurse to administer prescribed oral medications after the RN confirms swallowing safety

   Rationale: Recording intake and output for a stable client is a routine task appropriate for assistive personnel, while assessment is not. The practical nurse may administer medications within scope after the RN establishes that oral intake is safe and may reinforce established teaching. Swallowing assessment and the initial neurologic assessment require RN judgment and cannot be delegated.

3. 3.A provider order is entered for a 54-year-old client with heart failure: furosemide 40 mg IV now. The medication record shows that the client received 40 mg IV 15 minutes ago, but the order was not signed. What should the nurse do?

   • A.Document the dose as refused
   • B.Hold the dose and clarify the order and administration record
   • C.Give the medication because the order remains active
   • D.Ask another nurse to administer the medication

   Rationale: The nurse must prevent a possible duplicate dose by verifying the order and the documented administration with the provider or appropriate medication-system contact. Giving another dose or having a second nurse administer it does not resolve the discrepancy. A refusal did not occur, so that documentation would be inaccurate.

4. 4.During a home visit, a 72-year-old client with limited mobility says there is not enough money for both food and prescriptions. The client has missed several doses of an anticoagulant. Which action is the best initial response?

   • A.Assess the client's immediate health risks and connect the client with medication and food resources
   • B.Tell the client that medication adherence is essential
   • C.Recommend taking the anticoagulant every other day
   • D.Report the client to the prescriber for noncompliance

   Answer and rationale are in the full material.

5. 5.Refer to the client's chart. A 63-year-old client is admitted to a medical unit with worsening shortness of breath and edema. Which actions should the nurse take now? Select all that apply.

   • A.Ask the client to walk in the hallway to evaluate exercise tolerance
   • B.Encourage the client to drink 1 L of water to improve circulation
   • C.Place the client upright and apply oxygen as prescribed
   • D.Notify the provider or rapid response team about the worsening findings
   • E.Reassess respiratory status and oxygen saturation after intervention

   Answer and rationale are in the full material.