Question

A nurse caring for client an emergency department.

Answer 1

Correct Answers:

Increase intake of oral fluids.
Obtain a serum lactate level
Monitor serum glucose level
Administer an antibiotic
Infuse intravenous IV fluids
Obtain blood cultures

Rationale :

🔷 Increase intake of oral fluids: This helps maintain hydration and improves circulatory volume, especially important if IV access is delayed or if the client is stable.

🔷 Obtain a serum lactate level: Elevated lactate indicates tissue hypoperfusion, a key marker in diagnosing sepsis and septic shock early.

🔷 Monitor serum glucose level: Stress and infection often cause hyperglycemia, even in non-diabetics; glucose control is crucial in septic clients.

🔷 Administer an antibiotic: Broad-spectrum antibiotics should be started immediately after cultures to control infection and prevent progression to septic shock.

🔷 Infuse intravenous IV fluids: Crystalloid fluids (like NS or LR) are a first-line intervention for hypotension and improve organ perfusion.

🔷 Obtain blood cultures: These must be drawn before antibiotics to identify the causative organism and guide targeted therapy

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Answer 2

Correct Answers:

The code of ethics is not legally binding

Rationale :

💠 The ANA Code of Ethics provides moral and ethical guidance, but it is not enforceable by law.

💠 It helps nurses make decisions aligned with professional values and ethical standards.

💠 The code supports patient advocacy, respect, and integrity in care delivery.

💠 Though not legal, violations can lead to disciplinary actions through boards or employers.

💠 It is universal across practice settings, not limited by client’s health status or economics.

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Answer 3

Correct Answers:

Perform in- line suctioning for the client.

Rationale :

💠 Restlessness + SpO₂ of 90% in a ventilated patient suggests airway obstruction or secretion buildup.

💠 In-line suctioning helps remove secretions while maintaining PEEP and avoiding oxygen desaturation.

💠 It’s a priority intervention before drawing labs or documentation.

💠 It improves oxygenation and reduces the risk of hypoxia-induced complications.

💠 It is safe and effective in closed ventilator circuits, preserving lung recruitment.

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Answer 4

Correct Answers:

Develop learning objectives for use of the new

Rationale :

💠 The first step in any educational process is defining clear objectives.

💠 Objectives guide content development, evaluation methods, and learner expectations.

💠 Without objectives, teaching lacks focus and measurable outcomes.

💠 This step aligns training with desired competencies and supports effective learning.

💠 Helps prioritize critical knowledge and skills for safe device use.

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Answer 5

Correct Answers:

Decreased urine output

Rationale :

💠 Oliguria (<30 mL/hr) is one of the earliest and most reliable signs of organ hypoperfusion in sepsis.

💠 Kidneys respond early to hypotension and hypovolemia by conserving fluid.

💠 It's a clinical marker used in Sepsis-3 definition (qSOFA criteria).

💠 Urine output is easily measurable and often declines before hypotension or altered mental status.

💠 Helps assess renal perfusion and guides fluid resuscitation needs

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Answer 6

Correct Answers:

Confusion and increased respiratory rate

Rationale :

💠 Tachycardia (HR 120) and increased RR (28) are compensatory signs of early hypovolemia.

💠 Hypotension (118/100) trending from normotensive pressure indicates fluid volume depletion.

💠 Pallor, diaphoresis, and confusion suggest reduced cerebral and skin perfusion.

💠 ABG pH 7.35 with borderline CO₂ indicates early metabolic compensation.

💠 Nausea and Hgb of 37% reflect possible fluid shift, not anemia—still pointing to volume depletion.

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Answer 7

Correct Answers:

Medicare part A will assist with paying for in patient stay at a medical facility.

Rationale :

🔷 Medicare Part A covers inpatient care in hospitals, hospice, and skilled nursing facilities.

🔷 It helps reduce costs for hospital admissions, surgeries, and certain home health care.

🔷 It is often automatically enrolled if clients or spouses paid Medicare taxes while working.

🔷 Part B handles outpatient visits—not Part A or D.

🔷 Prescription drugs are not covered under Part A; that is handled by Part D or sometimes Part C (if enrolled in an Advantage Plan)

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Answer 8

Correct Answers:

Accountability

Rationale :

🟢 Accountability means the nurse takes ownership of actions, including errors.

🟢 Filing an incident report is an example of ethical and professional behavior.

🟢 It ensures that care errors are documented, reviewed, and used for quality improvement.

🟢 This principle supports transparency in practice and client safety.

🟢 It reflects the nurse's commitment to the Code of Ethics and regulatory standards.

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Answer 9

Correct Answers:

Poor feeding

Rationale :

🔴 RSV often presents in infants as poor feeding, lethargy, and respiratory distress.

🔴 Infants may have nasal flaring, retractions, or wheezing, even without high fever.

🔴 Bradycardia and hypothermia are late or rare signs.

🔴 Early detection involves watching for decreased intake, irritability, and fatigue.

🔴 Supportive care includes hydration, suctioning, and oxygen if needed.

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Answer 10

Correct Answers:

Cleanses client's skin around the stoma with deodorant soap

Rationale :

🟠 Deodorant soap can irritate skin and interfere with appliance adhesion.

🟠 Only mild, fragrance-free soap and water should be used to cleanse peristomal skin.

🟠 Skin irritation can lead to leakage, infection, and poor appliance seal.

🟠 Proper ostomy care includes accurate sizing, clean technique, and moisture protection.

🟠 Applying gauze temporarily over stoma is correct to absorb output during cleaning.

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RN Concept-Based Assessment Level 4 with NGN-2025 Summer

No.

1 :
A nurse caring for client an emergency department.

Answer Options

2 :
A nurse is discussing the American Nurses Association’s code of ethics with a newly licensed nurse. Which of the following information should the nurse include in the discussion?

3 :
A nurse is caring for a client who has acute distress syndrome and is receiving mechanical ventilation. The client is restless and has an oxygen saturation of 90%. Which of the following actions shou" the nurse task

4 :
A nurse working in the role of the staff development t coordinator is developing a training program for a group of nurses about the use of a new IV pump. Which of the steps should the nurse take first?

5 :
A nurse in an intensive care unit is assessing a client who has a localized bacterial infection. The nurse should identify which of the following findings as an early manifestation of sepsis?

6 :
A nurse in PACU is assessing a female client who is 30 min postoperative.

Answer Options

7 :
A nurse is teaching the adult child of an older adult client about Medicare. Which of the following information should the nurse include?

8 :
A nurse on a medical unit realizes she administered an incorrect dose of medication to a client. Which the following ethical principles is the nurse exhibiting by completing an incident report of the event?

9 :
A nurse is assessing an infant who has respiratory syncytial virus. Which of the following manifestation should the nurse expect?

10 :
A charge is supervising a newly licensed nurse who is changing an ostomy appliance for a client. The charge nurse should intervene for of the following actions by the newly licensed nurse?

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RN Concept-Based Assessment Level 4 with NGN-2025 Summer

No.

1 : A nurse caring for client an emergency department.

Answer Options

2 : A nurse is discussing the American Nurses Association’s code of ethics with a newly licensed nurse. Which of the following information should the nurse include in the discussion?

3 : A nurse is caring for a client who has acute distress syndrome and is receiving mechanical ventilation. The client is restless and has an oxygen saturation of 90%. Which of the following actions shou" the nurse task

4 : A nurse working in the role of the staff development t coordinator is developing a training program for a group of nurses about the use of a new IV pump. Which of the steps should the nurse take first?

5 : A nurse in an intensive care unit is assessing a client who has a localized bacterial infection. The nurse should identify which of the following findings as an early manifestation of sepsis?

6 : A nurse in PACU is assessing a female client who is 30 min postoperative.

Answer Options

7 : A nurse is teaching the adult child of an older adult client about Medicare. Which of the following information should the nurse include?

8 : A nurse on a medical unit realizes she administered an incorrect dose of medication to a client. Which the following ethical principles is the nurse exhibiting by completing an incident report of the event?

9 : A nurse is assessing an infant who has respiratory syncytial virus. Which of the following manifestation should the nurse expect?

10 : A charge is supervising a newly licensed nurse who is changing an ostomy appliance for a client. The charge nurse should intervene for of the following actions by the newly licensed nurse?

1 :
A nurse caring for client an emergency department.

2 :
A nurse is discussing the American Nurses Association’s code of ethics with a newly licensed nurse. Which of the following information should the nurse include in the discussion?

3 :
A nurse is caring for a client who has acute distress syndrome and is receiving mechanical ventilation. The client is restless and has an oxygen saturation of 90%. Which of the following actions shou" the nurse task

4 :
A nurse working in the role of the staff development t coordinator is developing a training program for a group of nurses about the use of a new IV pump. Which of the steps should the nurse take first?

5 :
A nurse in an intensive care unit is assessing a client who has a localized bacterial infection. The nurse should identify which of the following findings as an early manifestation of sepsis?

6 :
A nurse in PACU is assessing a female client who is 30 min postoperative.

7 :
A nurse is teaching the adult child of an older adult client about Medicare. Which of the following information should the nurse include?

8 :
A nurse on a medical unit realizes she administered an incorrect dose of medication to a client. Which the following ethical principles is the nurse exhibiting by completing an incident report of the event?

9 :
A nurse is assessing an infant who has respiratory syncytial virus. Which of the following manifestation should the nurse expect?

10 :
A charge is supervising a newly licensed nurse who is changing an ostomy appliance for a client. The charge nurse should intervene for of the following actions by the newly licensed nurse?