Nursing Fundamentals: Key Concepts and Clinical Applications
Patient Assignment and Prioritization
Scenario 1: A newly oriented nurse is working in the labor and delivery unit. Which client is
most appropriate for assignment?
o A multiparous client who is dilated 5 cm and 50% effaced.
Pharmacology and Patient Education
Scenario 2: A client with HIV has oral white lesions resembling milk curds and is prescribed
nystatin (Mycostatin) swish and swallow.
o Key Information: <mark style="background-color: #add8e6;">Oral hygiene should be
performed before the medication.</mark>
Respiratory Care and Positioning
Scenario 3: A client with emphysema is experiencing difficulty breathing. What is the optimal
position for this client?
o Sitting upright and forward with both arms supported on an over the bed table.
Fluid and Electrolyte Balance
Scenario 4: A client with chronic renal insufficiency (CRI) takes hydrochlorothiazide (HCTZ)
and furosemide (Lasix) daily. Their serum potassium is 4 mEq/L. What is the most likely cause?
o The client's renal function has affected their potassium level.
Telehealth and Professional Liability
Scenario 5: An RN provides telehealth services. Which action poses the greatest risk for
professional liability and potential malpractice?
, o <mark style="background-color: #ff6961;">Sending medical records to health
care providers via the Internet.</mark>
Neurological Disorders and Opioid Contraindications
Scenario 6: Which pathophysiologic response contraindicates opioid use (e.g., morphine) in
clients with increased intracranial pressure (ICP)?
o D. Opioids suppress respirations, which increases textPCO_2 and contributes to an
elevated ICP.
o Explanation: <mark style="background-color: #ff6961;">Respiratory depression
caused by opioids leads to increased textPCO_2, resulting in vasodilation and a further rise
in ICP. It can also mask early signs of intracranial bleeding.</mark>
Disaster Preparedness
Scenario 7: The charge nurse is alerted to an impending disaster with unknown specifics. What
initial instruction should be given to staff?
o D. Continue with current assignments until more instructions are received.
o Rationale: Maintaining routine care until specific directives are given prevents
unnecessary chaos and ensures ongoing patient needs are met.
Delegation and Patient Assessment
Scenario 8: A nurse assesses a client with sudden vital sign changes and needs to check for
advanced directives. What action should the nurse take?
o D. Call for the charge nurse to check the advanced directive while continuing to
assess the client.
o Rationale: In a worsening situation, the nurse should remain with the client for continuous
assessment while delegating the task of checking advanced directives to ensure timely
information retrieval.
, Preoperative Care
Scenario 9: A nurse prepares a client for surgery with UAP assistance. Which task is the nurse's
responsibility?
o D. Offer the client emotional support.
o Rationale: Providing emotional support and addressing client concerns requires the
therapeutic communication skills of a registered nurse.
Staffing and Patient Acuity
Scenario 10: A UAP from labor and delivery/newborn nursery is temporarily assigned to the
postoperative unit. Which client is most appropriate for this UAP?
o C. A woman who had a hip replacement and may be transferred to the home care
unit.
o Rationale: This client's care needs are likely to be more routine and less specialized
compared to the other options.
Neurological Assessment and Increased ICP
Scenario 11: A client with a head injury attempts to crawl out of bed and reports seeing bugs.
Vital signs are stable, and textO_2 saturation is 98%. What is the priority intervention?
o C. Notify the health care provider of the change in mental status.
o <mark style="background-color: #ff6961;">Warning:</mark> A change in
mental status is an early and critical sign of increased ICP and requires immediate medical
attention.
Conscious Sedation
Scenario 12: A client receiving midazolam hydrochloride (Versed) for conscious sedation
exhibits slurred speech and diplopia. What action should the nurse take?
o D. Continue to monitor the client.
Patient Assignment and Prioritization
Scenario 1: A newly oriented nurse is working in the labor and delivery unit. Which client is
most appropriate for assignment?
o A multiparous client who is dilated 5 cm and 50% effaced.
Pharmacology and Patient Education
Scenario 2: A client with HIV has oral white lesions resembling milk curds and is prescribed
nystatin (Mycostatin) swish and swallow.
o Key Information: <mark style="background-color: #add8e6;">Oral hygiene should be
performed before the medication.</mark>
Respiratory Care and Positioning
Scenario 3: A client with emphysema is experiencing difficulty breathing. What is the optimal
position for this client?
o Sitting upright and forward with both arms supported on an over the bed table.
Fluid and Electrolyte Balance
Scenario 4: A client with chronic renal insufficiency (CRI) takes hydrochlorothiazide (HCTZ)
and furosemide (Lasix) daily. Their serum potassium is 4 mEq/L. What is the most likely cause?
o The client's renal function has affected their potassium level.
Telehealth and Professional Liability
Scenario 5: An RN provides telehealth services. Which action poses the greatest risk for
professional liability and potential malpractice?
, o <mark style="background-color: #ff6961;">Sending medical records to health
care providers via the Internet.</mark>
Neurological Disorders and Opioid Contraindications
Scenario 6: Which pathophysiologic response contraindicates opioid use (e.g., morphine) in
clients with increased intracranial pressure (ICP)?
o D. Opioids suppress respirations, which increases textPCO_2 and contributes to an
elevated ICP.
o Explanation: <mark style="background-color: #ff6961;">Respiratory depression
caused by opioids leads to increased textPCO_2, resulting in vasodilation and a further rise
in ICP. It can also mask early signs of intracranial bleeding.</mark>
Disaster Preparedness
Scenario 7: The charge nurse is alerted to an impending disaster with unknown specifics. What
initial instruction should be given to staff?
o D. Continue with current assignments until more instructions are received.
o Rationale: Maintaining routine care until specific directives are given prevents
unnecessary chaos and ensures ongoing patient needs are met.
Delegation and Patient Assessment
Scenario 8: A nurse assesses a client with sudden vital sign changes and needs to check for
advanced directives. What action should the nurse take?
o D. Call for the charge nurse to check the advanced directive while continuing to
assess the client.
o Rationale: In a worsening situation, the nurse should remain with the client for continuous
assessment while delegating the task of checking advanced directives to ensure timely
information retrieval.
, Preoperative Care
Scenario 9: A nurse prepares a client for surgery with UAP assistance. Which task is the nurse's
responsibility?
o D. Offer the client emotional support.
o Rationale: Providing emotional support and addressing client concerns requires the
therapeutic communication skills of a registered nurse.
Staffing and Patient Acuity
Scenario 10: A UAP from labor and delivery/newborn nursery is temporarily assigned to the
postoperative unit. Which client is most appropriate for this UAP?
o C. A woman who had a hip replacement and may be transferred to the home care
unit.
o Rationale: This client's care needs are likely to be more routine and less specialized
compared to the other options.
Neurological Assessment and Increased ICP
Scenario 11: A client with a head injury attempts to crawl out of bed and reports seeing bugs.
Vital signs are stable, and textO_2 saturation is 98%. What is the priority intervention?
o C. Notify the health care provider of the change in mental status.
o <mark style="background-color: #ff6961;">Warning:</mark> A change in
mental status is an early and critical sign of increased ICP and requires immediate medical
attention.
Conscious Sedation
Scenario 12: A client receiving midazolam hydrochloride (Versed) for conscious sedation
exhibits slurred speech and diplopia. What action should the nurse take?
o D. Continue to monitor the client.
