Health and Healing IV

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Sample questions from Health and Healing IV

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

1. 1.During discharge teaching at a medical-surgical unit, a 46-year-old client with newly diagnosed heart failure says, "I can read the medication sheet, but I do not understand what to do if I gain weight." The client is alert, has BP 128/76 mm Hg, HR 82/min, and SpO2 97% on room air. Which action should the nurse take first?

   • A.Give the client a more detailed written handout about heart failure.
   • B.Ask the client to explain in their own words what action to take for a specified weight gain.
   • C.Ask the client's family to review the medication sheet after discharge.
   • D.Document that written education was provided.

   Rationale: Asking the client to explain the plan in their own words is a teach-back method that checks understanding without shaming the client. A more detailed handout may not address the client's difficulty applying the instructions, and relying on family does not establish the client's understanding. Documenting education alone does not verify learning. The exam takeaway is to assess comprehension with teach-back and reteach as needed.

2. 2.In an outpatient infusion clinic, a 57-year-old client arrives for a prescribed IV medication. The order reads "infuse 1,000 mL over 4 hr," but the medication administration record lists 1,000 mL over 8 hr. The client is stable with BP 124/70 mm Hg, HR 76/min, RR 16/min, and SpO2 98% on room air. What should the nurse do?

   • A.Begin the infusion at the rate on the provider's order.
   • B.Begin the infusion at the rate on the medication administration record.
   • C.Ask the client which infusion duration was used at the previous visit.
   • D.Clarify the discrepancy with the prescribing provider before starting the infusion.

   Rationale: The conflicting infusion durations create an unsafe ambiguity, so the nurse must clarify the order before administering the fluid. Choosing either rate without clarification could cause harm, and the client's recollection cannot replace a valid prescription. The client is stable, so there is time to resolve the discrepancy before treatment. The exam takeaway is to question and clarify unclear or conflicting orders.

3. 3.At change of shift on a pediatric medical unit, a 9-year-old client has a peripheral IV infusing maintenance fluid at the prescribed rate. The client is awake, reports no pain, and has stable vital signs. Which task is appropriate for the registered nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Measure and report the client's oral intake and urine output.
   • B.Assess the IV site for signs of infiltration.
   • C.Teach the client how to protect the IV site while walking.
   • D.Change the IV infusion rate when the pump alarms.

   Rationale: Measuring and reporting intake and output is a routine, predictable task that can be delegated to a trained UAP, with the RN retaining responsibility for interpreting the findings. Assessing the IV site, changing an infusion rate, and teaching require nursing judgment or education and are not appropriate UAP tasks. The exam takeaway is to delegate data collection, not assessment, clinical decisions, or teaching.

4. 4.Refer to the client's chart. In the emergency department, a 3-year-old client receiving IV fluids becomes increasingly restless. Which findings require the nurse to stop the infusion and promptly assess the IV site? Select all that apply.

   • A.The left hand is more swollen at 1000 than it was at 0800.
   • B.The IV site is cool to the touch at 1000.
   • C.The dressing is damp and the IV pump has alarmed twice.
   • D.The child's temperature is 37.2 C at 1000.
   • E.The heart rate is 112/min at 1000, down from 120/min at 0800.

   Answer and rationale are in the full material.

5. 5.A client states, "I signed the form, but I still do not understand the risks of this procedure." In a preoperative area, a 34-year-old client is scheduled for a procedure under sedation; BP is 118/72 mm Hg, HR 80/min, and SpO2 98% on room air. What is the nurse's priority action?

   • A.Document that the client signed the consent form and continue preparation.
   • B.Explain the procedure's risks and ask the client to sign the form again.
   • C.Notify the procedural provider that the client has unanswered questions before proceeding.
   • D.Ask a family member to explain the procedure to the client.

   Answer and rationale are in the full material.