PNR 207/PNR207 Exam 1 V3 | Transition to PN
Practice - Capstone Q&A with Rationale | Fortis
College
1. A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse
assess first?
A. A client who is 2 days postoperative and has not had a bowel movement.
B. A client with chronic obstructive pulmonary disease (COPD) reporting shortness of
breath while ambulating.
C. A client with a history of heart failure who reports a 2-pound weight gain in 24 hours.
D. A client who has a blood pressure of 160/94 mmHg and is requesting pain medication.
Correct Answer: C
Explanation: The client with heart failure and rapid weight gain must be assessed first
because it indicates fluid volume overload. Weight gain of more than 2 pounds in a single
day is a clinical indicator that requires immediate intervention to prevent pulmonary
edema. Other clients are stable or have expected findings for their conditions.
2. A Licensed Practical Nurse (LPN) is assisting with the plan of care for a client who is
receiving total parenteral nutrition (TPN). Which of the following tasks is appropriate for the
nurse to perform?
A. Monitor the client’s capillary blood glucose levels every 6 hours.
B. Change the TPN infusion tubing every 72 hours.
,C. Adjust the infusion rate of the TPN if the client shows signs of hyperglycemia.
D. Administer IV bolus medications through the TPN line.
Correct Answer: A
Explanation: Monitoring blood glucose is a critical component of caring for a client on TPN
due to the high dextrose concentration. TPN tubing is typically changed every 24 hours to
prevent bacterial growth. The PN should not adjust infusion rates independently or use the
TPN line for other medications.
3. A nurse is preparing to delegate tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for the nurse to delegate?
A. Evaluating a client’s response to an analgesic.
B. Assisting a client with oral hygiene after a meal.
C. Teaching a client how to use a walker.
D. Assessing a new admission’s skin integrity.
Correct Answer: B
Explanation: Oral hygiene is a standard task within the scope of practice for a UAP.
Evaluation, teaching, and assessment are professional nursing responsibilities that cannot
be delegated to unlicensed staff. The PN must ensure that delegated tasks are appropriate
for the staff member’s skill level.
, 4. A nurse is caring for a client who has a newly placed tracheostomy. Which of the following
items should the nurse ensure is kept at the bedside?
A. A bottle of sterile normal saline for irrigation.
B. A sterile suture removal kit.
C. An extra tracheostomy tube of the same size and one size smaller.
D. A manual resuscitation bag with a face mask.
Correct Answer: C
Explanation: Safety equipment at the bedside of a tracheostomy client must include
replacement tubes in case of accidental decannulation. Having a smaller size available is
crucial if the stoma begins to close or becomes difficult to re-cannulate. This is a standard
safety protocol for airway management in post-surgical units.
5. Which of the following actions by the nurse demonstrates the ethical principle of
autonomy?
A. Ensuring the client receives their medication exactly as scheduled.
B. Allowing a client to decide which time they would like to perform their morning care.
C. Telling the client the truth about their terminal diagnosis.
D. Providing the same quality of care to all clients regardless of their background.
Correct Answer: B
Practice - Capstone Q&A with Rationale | Fortis
College
1. A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse
assess first?
A. A client who is 2 days postoperative and has not had a bowel movement.
B. A client with chronic obstructive pulmonary disease (COPD) reporting shortness of
breath while ambulating.
C. A client with a history of heart failure who reports a 2-pound weight gain in 24 hours.
D. A client who has a blood pressure of 160/94 mmHg and is requesting pain medication.
Correct Answer: C
Explanation: The client with heart failure and rapid weight gain must be assessed first
because it indicates fluid volume overload. Weight gain of more than 2 pounds in a single
day is a clinical indicator that requires immediate intervention to prevent pulmonary
edema. Other clients are stable or have expected findings for their conditions.
2. A Licensed Practical Nurse (LPN) is assisting with the plan of care for a client who is
receiving total parenteral nutrition (TPN). Which of the following tasks is appropriate for the
nurse to perform?
A. Monitor the client’s capillary blood glucose levels every 6 hours.
B. Change the TPN infusion tubing every 72 hours.
,C. Adjust the infusion rate of the TPN if the client shows signs of hyperglycemia.
D. Administer IV bolus medications through the TPN line.
Correct Answer: A
Explanation: Monitoring blood glucose is a critical component of caring for a client on TPN
due to the high dextrose concentration. TPN tubing is typically changed every 24 hours to
prevent bacterial growth. The PN should not adjust infusion rates independently or use the
TPN line for other medications.
3. A nurse is preparing to delegate tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for the nurse to delegate?
A. Evaluating a client’s response to an analgesic.
B. Assisting a client with oral hygiene after a meal.
C. Teaching a client how to use a walker.
D. Assessing a new admission’s skin integrity.
Correct Answer: B
Explanation: Oral hygiene is a standard task within the scope of practice for a UAP.
Evaluation, teaching, and assessment are professional nursing responsibilities that cannot
be delegated to unlicensed staff. The PN must ensure that delegated tasks are appropriate
for the staff member’s skill level.
, 4. A nurse is caring for a client who has a newly placed tracheostomy. Which of the following
items should the nurse ensure is kept at the bedside?
A. A bottle of sterile normal saline for irrigation.
B. A sterile suture removal kit.
C. An extra tracheostomy tube of the same size and one size smaller.
D. A manual resuscitation bag with a face mask.
Correct Answer: C
Explanation: Safety equipment at the bedside of a tracheostomy client must include
replacement tubes in case of accidental decannulation. Having a smaller size available is
crucial if the stoma begins to close or becomes difficult to re-cannulate. This is a standard
safety protocol for airway management in post-surgical units.
5. Which of the following actions by the nurse demonstrates the ethical principle of
autonomy?
A. Ensuring the client receives their medication exactly as scheduled.
B. Allowing a client to decide which time they would like to perform their morning care.
C. Telling the client the truth about their terminal diagnosis.
D. Providing the same quality of care to all clients regardless of their background.
Correct Answer: B
