WEST COAST BLOCK 4 EXAM-ALL QUESTIONS AND ANSWERS
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1. A registered nurse is prioritizing client care after receiving the shift report. Which client
should the nurse assess first?
A. A client post-appendectomy reporting incisional pain rated 6/10.
B. A client with chronic obstructive pulmonary disease (COPD) with an oxygen saturation of
91% on 2 L/min via nasal cannula.
C. A client admitted with heart failure who experienced a 2-pound weight gain overnight and
reports mild shortness of breath upon exertion.
D. A client with a total hip arthroplasty whose affected leg is internally rotated, shortened, and
presenting with severe pain.
Answer: D
The nurse must prioritize the client with signs of a hip dislocation (internal rotation, limb
shortening, and severe pain) because it represents an immediate vascular and neurological
compromise requiring emergent intervention. The remaining clients represent expected
clinical findings or stable conditions that can be addressed after the acute surgical
complication is managed.
2. A nurse prepares to administer digoxin 0.25 mg IV push to a client in atrial fibrillation.
Prior to administration, which action is essential for the nurse to perform?
A. Check the client's blood pressure while sitting and standing.
B. Assess the apical pulse for 1 full minute.
C. Review the client's serum calcium level.
D. Administer a test dose of 0.05 mg to assess tolerance.
Answer: B
Digoxin is a cardiac glycoside that reduces heart rate and increases cardiac contractility. The
nurse must assess the apical heart rate for a full 60 seconds prior to administration; if the
pulse rate is under 60 beats per minute (or per institutional protocol), the medication must be
withheld and the provider notified to prevent life-threatening bradycardia.
,3. A patient diagnosed with major depressive disorder is started on baseline
pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI). Which instruction
is most critical for the nurse to include in the client teaching?
A. Limit intake of tyramine-rich foods such as aged cheeses and red wine.
B. Expect maximum therapeutic response to occur within 24 to 48 hours.
C. Report any sudden increases in energy or suicidal ideation immediately.
D. Discontinue the medication as soon as mood improves to prevent dependency.
Answer: C
Clients taking SSRIs experience an increase in energy and activation prior to significant
therapeutic improvement in mood, which can temporarily increase the risk of acting on
suicidal ideation. Monitoring for and reporting changes in thought patterns or emergent
suicidal thoughts is critical during early treatment phase.
4. A registered nurse delegates tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate to delegate?
A. Assisting a stable post-operative client to ambulate for the first time.
B. Documenting the strict intake and output of a client receiving continuous bladder irrigation.
C. Educating a newly diagnosed diabetic client on blood glucose self-monitoring techniques.
D. Evaluating the pain level of a client 30 minutes after oral analgesic administration.
Answer: B
Recording straightforward intake and output values for a stable client falls within the scope of
practice for unlicensed assistive personnel. Initial ambulation assessment, formal patient
education, and nursing evaluations (such as pain re-assessment) require specialized clinical
judgment and cannot be delegated to assistive staff.
5. A client admitted with severe preeclampsia is receiving an intravenous infusion of
magnesium sulfate. Which assessment finding indicates potential magnesium toxicity?
A. Deep tendon reflexes rated at 2+.
B. Urine output of 45 mL per hour.
C. Respiratory rate of 10 breaths per minute.
,D. Blood pressure of 148/92 mmHg.
Answer: C
Magnesium sulfate acts as a central nervous system depressant. A respiratory rate under 12
breaths per minute, diminished or absent deep tendon reflexes, and oliguria are key indicators
of magnesium toxicity, necessitating immediate cessation of the infusion and potential
administration of calcium gluconate.
6. A client with type 1 diabetes mellitus presents to the emergency department with blood
glucose 480 mg/dL, positive serum ketones, and Kussmaul respirations. Which physician
order should the nurse implement first?
A. Infuse 0.9% Normal Saline at 1,000 mL/hr.
B. Administer Regular Insulin 10 units IV push.
C. Obtain an electrocardiogram (ECG).
D. Draw blood sample for arterial blood gas analysis.
Answer: A
The primary immediate requirement in Diabetic Ketoacidosis (DKA) management is
aggressive fluid resuscitation to restore intravascular volume, improve renal perfusion, and
clear circulating ketones. Insulin administration prior to adequate fluid replacement can lead
to vascular collapse as water shifts into cells along with glucose.
7. A nurse cares for a client who underwent a thyroidectomy 12 hours ago. The nurse
observes continuous muscle twitching and a positive Chvostek's sign. Which medication
should the nurse anticipate administering?
A. Potassium chloride.
B. Calcium gluconate.
C. Sodium bicarbonate.
D. Calcitonin.
Answer: B
Accidental trauma or removal of the parathyroid glands during thyroid surgery leads to
hypocalcemia, characterized by neuromuscular irritability, tetany, and positive Chvostek and
Trousseau signs. Intravenous calcium gluconate is the indicated acute emergency treatment to
restore serum calcium levels.
, 8. Which clinical finding in a patient who sustained a closed head injury indicates
worsening intracranial pressure (ICP)?
A. Tachycardia with a narrowed pulse pressure.
B. Widening pulse pressure with bradycardia.
C. Equal, rapid pupil responses to light bilaterally.
D. Increase in motor activity and generalized agitation.
Answer: B
Cushing's triad is a classic late sign of significantly elevated intracranial pressure, consisting
of hypertension with a widening pulse pressure (elevated systolic with stable/decreased
diastolic), bradycardia, and irregular/altered respiratory patterns.
9. A pediatric client with acute asthma exacerbation is receiving continuous nebulized
albuterol. The nurse should carefully monitor the client for which adverse systemic effect?
A. Hypokalemia.
B. Hypercalcemia.
C. Bradycardia.
D. Hyponatremia.
Answer: A
Beta-2 adrenergic agonists like albuterol promote the movement of potassium from
extracellular fluid into the intracellular compartment, which can precipitate hypokalemia,
alongside expected sympathomimetic effects like tachycardia and tremors.
10. A nurse is providing discharge instructions to a client prescribed warfarin following
mechanical heart valve replacement. Which statement made by the client indicates a need
for further teaching?
A. "I will need regular laboratory blood tests to check my INR."
B. "I should use a soft-bristled toothbrush and an electric razor."
C. "I am going to increase my daily intake of green leafy vegetables to boost my immune
system."
D. "I must contact my primary care provider before taking over-the-counter pain medications."
PLUS DETAILED RATIONALES | COMPLETE STUDYGUIDE |
DOWNLOAD INSTANT PDF 2027-2028
1. A registered nurse is prioritizing client care after receiving the shift report. Which client
should the nurse assess first?
A. A client post-appendectomy reporting incisional pain rated 6/10.
B. A client with chronic obstructive pulmonary disease (COPD) with an oxygen saturation of
91% on 2 L/min via nasal cannula.
C. A client admitted with heart failure who experienced a 2-pound weight gain overnight and
reports mild shortness of breath upon exertion.
D. A client with a total hip arthroplasty whose affected leg is internally rotated, shortened, and
presenting with severe pain.
Answer: D
The nurse must prioritize the client with signs of a hip dislocation (internal rotation, limb
shortening, and severe pain) because it represents an immediate vascular and neurological
compromise requiring emergent intervention. The remaining clients represent expected
clinical findings or stable conditions that can be addressed after the acute surgical
complication is managed.
2. A nurse prepares to administer digoxin 0.25 mg IV push to a client in atrial fibrillation.
Prior to administration, which action is essential for the nurse to perform?
A. Check the client's blood pressure while sitting and standing.
B. Assess the apical pulse for 1 full minute.
C. Review the client's serum calcium level.
D. Administer a test dose of 0.05 mg to assess tolerance.
Answer: B
Digoxin is a cardiac glycoside that reduces heart rate and increases cardiac contractility. The
nurse must assess the apical heart rate for a full 60 seconds prior to administration; if the
pulse rate is under 60 beats per minute (or per institutional protocol), the medication must be
withheld and the provider notified to prevent life-threatening bradycardia.
,3. A patient diagnosed with major depressive disorder is started on baseline
pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI). Which instruction
is most critical for the nurse to include in the client teaching?
A. Limit intake of tyramine-rich foods such as aged cheeses and red wine.
B. Expect maximum therapeutic response to occur within 24 to 48 hours.
C. Report any sudden increases in energy or suicidal ideation immediately.
D. Discontinue the medication as soon as mood improves to prevent dependency.
Answer: C
Clients taking SSRIs experience an increase in energy and activation prior to significant
therapeutic improvement in mood, which can temporarily increase the risk of acting on
suicidal ideation. Monitoring for and reporting changes in thought patterns or emergent
suicidal thoughts is critical during early treatment phase.
4. A registered nurse delegates tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate to delegate?
A. Assisting a stable post-operative client to ambulate for the first time.
B. Documenting the strict intake and output of a client receiving continuous bladder irrigation.
C. Educating a newly diagnosed diabetic client on blood glucose self-monitoring techniques.
D. Evaluating the pain level of a client 30 minutes after oral analgesic administration.
Answer: B
Recording straightforward intake and output values for a stable client falls within the scope of
practice for unlicensed assistive personnel. Initial ambulation assessment, formal patient
education, and nursing evaluations (such as pain re-assessment) require specialized clinical
judgment and cannot be delegated to assistive staff.
5. A client admitted with severe preeclampsia is receiving an intravenous infusion of
magnesium sulfate. Which assessment finding indicates potential magnesium toxicity?
A. Deep tendon reflexes rated at 2+.
B. Urine output of 45 mL per hour.
C. Respiratory rate of 10 breaths per minute.
,D. Blood pressure of 148/92 mmHg.
Answer: C
Magnesium sulfate acts as a central nervous system depressant. A respiratory rate under 12
breaths per minute, diminished or absent deep tendon reflexes, and oliguria are key indicators
of magnesium toxicity, necessitating immediate cessation of the infusion and potential
administration of calcium gluconate.
6. A client with type 1 diabetes mellitus presents to the emergency department with blood
glucose 480 mg/dL, positive serum ketones, and Kussmaul respirations. Which physician
order should the nurse implement first?
A. Infuse 0.9% Normal Saline at 1,000 mL/hr.
B. Administer Regular Insulin 10 units IV push.
C. Obtain an electrocardiogram (ECG).
D. Draw blood sample for arterial blood gas analysis.
Answer: A
The primary immediate requirement in Diabetic Ketoacidosis (DKA) management is
aggressive fluid resuscitation to restore intravascular volume, improve renal perfusion, and
clear circulating ketones. Insulin administration prior to adequate fluid replacement can lead
to vascular collapse as water shifts into cells along with glucose.
7. A nurse cares for a client who underwent a thyroidectomy 12 hours ago. The nurse
observes continuous muscle twitching and a positive Chvostek's sign. Which medication
should the nurse anticipate administering?
A. Potassium chloride.
B. Calcium gluconate.
C. Sodium bicarbonate.
D. Calcitonin.
Answer: B
Accidental trauma or removal of the parathyroid glands during thyroid surgery leads to
hypocalcemia, characterized by neuromuscular irritability, tetany, and positive Chvostek and
Trousseau signs. Intravenous calcium gluconate is the indicated acute emergency treatment to
restore serum calcium levels.
, 8. Which clinical finding in a patient who sustained a closed head injury indicates
worsening intracranial pressure (ICP)?
A. Tachycardia with a narrowed pulse pressure.
B. Widening pulse pressure with bradycardia.
C. Equal, rapid pupil responses to light bilaterally.
D. Increase in motor activity and generalized agitation.
Answer: B
Cushing's triad is a classic late sign of significantly elevated intracranial pressure, consisting
of hypertension with a widening pulse pressure (elevated systolic with stable/decreased
diastolic), bradycardia, and irregular/altered respiratory patterns.
9. A pediatric client with acute asthma exacerbation is receiving continuous nebulized
albuterol. The nurse should carefully monitor the client for which adverse systemic effect?
A. Hypokalemia.
B. Hypercalcemia.
C. Bradycardia.
D. Hyponatremia.
Answer: A
Beta-2 adrenergic agonists like albuterol promote the movement of potassium from
extracellular fluid into the intracellular compartment, which can precipitate hypokalemia,
alongside expected sympathomimetic effects like tachycardia and tremors.
10. A nurse is providing discharge instructions to a client prescribed warfarin following
mechanical heart valve replacement. Which statement made by the client indicates a need
for further teaching?
A. "I will need regular laboratory blood tests to check my INR."
B. "I should use a soft-bristled toothbrush and an electric razor."
C. "I am going to increase my daily intake of green leafy vegetables to boost my immune
system."
D. "I must contact my primary care provider before taking over-the-counter pain medications."
