N432 Test 2: Priority Questions With
Correct Answers
The nurse is caring for clients on a medical unit. Which client should the nurse
assess first?
a. the client diagnosed with COPD who has a pulse oximeter reading of 93%
b. the client diagnosed with CHF who has bilateral 4+ peripheral edema
c. the client diagnosed with pneumonia who has a temperature of 100 degrees F
d. the client diagnosed the Guillian-Barre syndrome who is unable to feel the
hips - ANSWER d
Which medication should the nurse administer first after receiving the morning
shift report?
a. the IVPB antibiotic to the client admitted at 0530 this morning
b. the sliding scale short-acting insulin to the client with diabetes
c. the non-narcotic pain medication to a client with a headache
d. the proton-pump inhibitor to the client with a peptic ulcer - ANSWER a
The nurse in a critical care unit is administering medications to a client. Which
intervention should the nurse implement first?
a. check the radial pulse before administering digoxin, a cardiac glycoside
b. monitor the oxygen saturation before administering the bronchodilator
c. obtain the latest PTT results on the client with a heparin drip
d. administer the mucosal barrier agent to the client who is NPO - ANSWER c
The surgical nurse is admitting a client to the operating room. Which information
would require the nurse to call a time-out?
a. the client is drowsy from the preoperative medication and drifts off to sleep
b. the consent form lists a left knee, but the client tells the nurse it is the right
knee
c. the surgical technician cannot find the surgeon's preferred surgical tray
d. the client states his or her name and birth date as it appears in the client -
ANSWER b
The nurse is administering medications at 1800 to a client and uses the following
medication administration record (MAR). Which interventions should the nurse
implement first?
, a. assess the client's potassium and digoxin levels
b. monitor the client's partial thromboplastin level
c. check the client's international normalized ratio (INR)
d. verify the client's name and identification (ID) number with the MAR - ANSWER
c
The nurse is administering medications to clients on a medical unit. Which
medications should the nurse question administering?
a. the steroid, prednisone, to the client diagnosed with COPD
b. the anticoagulant, enoxaprin (Lovenox), to a client who had knee surgery
c. the antiplatelet, ticlopidine (Ticlid), to a client being prepared for surgery
d. the ACE inhibitor, captopril (Capoten), to a client who has a blood pressure
(BP) of 100/68 - ANSWER c
The nurse is caring for a client who has a chest tube, Which interventions should
the nurse implement? Rank the interventions in order of performance.
a. assess the client's lung sounds
b. note the amount of suction being used
c. check the chest tube dressing for drainage
d. make sure that the chest tube is securely taped
e. place bottle of sterile saline at the bedside - ANSWER abcde
The nurse is preparing to administer the third unit of packed red blood cells
(PRBCs) to a client with a bleeding gastric ulcer. Which interventions should the
nurse implement? Select all that apply.
a. hang a bag of D5NS to keep open (TKO)
b. change the blood administration set
c. check the client's current vital signs
d. assess for allergies to blood products
e. obtain a blood warmer for the blood - ANSWER bc
The nurse is assessing clients on a pediatric unit. Which assessment data is
priority?
a. the 6-year-old client diagnosed with leukemia who is sucking is thumb
b. the 9-year-old client diagnosed with ulcerative colitis who has bloody diarrhea
c. the 13-year-old client diagnosed with cystic fibrosis (CF) who gas a pulse
oximeter reading of 91%
d. the 15-year-old client diagnosed with syphilis who is allergic to penicillin -
ANSWER c
The home health nurse is caring for a client diagnosed with COPD. Which client
problem is priority?
Correct Answers
The nurse is caring for clients on a medical unit. Which client should the nurse
assess first?
a. the client diagnosed with COPD who has a pulse oximeter reading of 93%
b. the client diagnosed with CHF who has bilateral 4+ peripheral edema
c. the client diagnosed with pneumonia who has a temperature of 100 degrees F
d. the client diagnosed the Guillian-Barre syndrome who is unable to feel the
hips - ANSWER d
Which medication should the nurse administer first after receiving the morning
shift report?
a. the IVPB antibiotic to the client admitted at 0530 this morning
b. the sliding scale short-acting insulin to the client with diabetes
c. the non-narcotic pain medication to a client with a headache
d. the proton-pump inhibitor to the client with a peptic ulcer - ANSWER a
The nurse in a critical care unit is administering medications to a client. Which
intervention should the nurse implement first?
a. check the radial pulse before administering digoxin, a cardiac glycoside
b. monitor the oxygen saturation before administering the bronchodilator
c. obtain the latest PTT results on the client with a heparin drip
d. administer the mucosal barrier agent to the client who is NPO - ANSWER c
The surgical nurse is admitting a client to the operating room. Which information
would require the nurse to call a time-out?
a. the client is drowsy from the preoperative medication and drifts off to sleep
b. the consent form lists a left knee, but the client tells the nurse it is the right
knee
c. the surgical technician cannot find the surgeon's preferred surgical tray
d. the client states his or her name and birth date as it appears in the client -
ANSWER b
The nurse is administering medications at 1800 to a client and uses the following
medication administration record (MAR). Which interventions should the nurse
implement first?
, a. assess the client's potassium and digoxin levels
b. monitor the client's partial thromboplastin level
c. check the client's international normalized ratio (INR)
d. verify the client's name and identification (ID) number with the MAR - ANSWER
c
The nurse is administering medications to clients on a medical unit. Which
medications should the nurse question administering?
a. the steroid, prednisone, to the client diagnosed with COPD
b. the anticoagulant, enoxaprin (Lovenox), to a client who had knee surgery
c. the antiplatelet, ticlopidine (Ticlid), to a client being prepared for surgery
d. the ACE inhibitor, captopril (Capoten), to a client who has a blood pressure
(BP) of 100/68 - ANSWER c
The nurse is caring for a client who has a chest tube, Which interventions should
the nurse implement? Rank the interventions in order of performance.
a. assess the client's lung sounds
b. note the amount of suction being used
c. check the chest tube dressing for drainage
d. make sure that the chest tube is securely taped
e. place bottle of sterile saline at the bedside - ANSWER abcde
The nurse is preparing to administer the third unit of packed red blood cells
(PRBCs) to a client with a bleeding gastric ulcer. Which interventions should the
nurse implement? Select all that apply.
a. hang a bag of D5NS to keep open (TKO)
b. change the blood administration set
c. check the client's current vital signs
d. assess for allergies to blood products
e. obtain a blood warmer for the blood - ANSWER bc
The nurse is assessing clients on a pediatric unit. Which assessment data is
priority?
a. the 6-year-old client diagnosed with leukemia who is sucking is thumb
b. the 9-year-old client diagnosed with ulcerative colitis who has bloody diarrhea
c. the 13-year-old client diagnosed with cystic fibrosis (CF) who gas a pulse
oximeter reading of 91%
d. the 15-year-old client diagnosed with syphilis who is allergic to penicillin -
ANSWER c
The home health nurse is caring for a client diagnosed with COPD. Which client
problem is priority?
