RPN Client Assessment and Planning 4 — Questions and Answers
Question 1: A client with diabetes has a blood glucose of 52 mg/dL and is alert and oriented. The RPN should FIRST:
- Administer IV dextrose immediately
- Give 15 grams of fast-acting carbohydrate by mouth (Correct answer)
- Notify the physician before taking action
- Recheck blood glucose in one hour
Correct answer: Give 15 grams of fast-acting carbohydrate by mouth
For a conscious hypoglycemic client, the 15-15 rule applies: give 15g of fast-acting carbohydrate and recheck in 15 minutes.
Question 2: An RPN notes that a client's urinary output has been 200 mL over the past 8 hours. This finding is classified as:
- Polyuria
- Anuria
- Oliguria (Correct answer)
- Normal output
Correct answer: Oliguria
Oliguria is defined as urine output less than 400 mL in 24 hours, making 200 mL in 8 hours a concerning finding.
Question 3: Which assessment finding in a postpartum client requires IMMEDIATE intervention?
- Uterine fundus firm at the umbilicus
- Lochia rubra with small clots on day 1
- Blood pressure 160/110 mmHg with headache (Correct answer)
- Mild perineal discomfort at the episiotomy site
Correct answer: Blood pressure 160/110 mmHg with headache
A blood pressure of 160/110 mmHg with headache in a postpartum client signals postpartum preeclampsia, a medical emergency.
Question 4: A client is admitted with suspected deep vein thrombosis (DVT). Which assessment finding is MOST consistent with this diagnosis?
- Bilateral leg edema that is painless
- Unilateral calf pain, warmth, and redness (Correct answer)
- Cool, pale skin in the affected extremity
- Absence of dorsalis pedis pulse
Correct answer: Unilateral calf pain, warmth, and redness
Unilateral calf pain, warmth, and erythema are classic signs of DVT caused by clot formation and inflammation.
Question 5: When setting priorities using Maslow's hierarchy, which client need should the RPN address FIRST?
- A client requesting information about discharge medications
- A client expressing fear about an upcoming procedure
- A client with an oxygen saturation of 88% (Correct answer)
- A client needing assistance ambulating to the bathroom
Correct answer: A client with an oxygen saturation of 88%
Physiological needs such as oxygenation are the highest priority; SpO2 of 88% indicates hypoxia requiring immediate action.
Question 6: A client's Braden Scale score is 14. How should the RPN interpret this finding?
- No risk for pressure injury
- Mild risk for pressure injury (Correct answer)
- High risk for pressure injury
- Severe risk requiring immediate wound care
Correct answer: Mild risk for pressure injury
A Braden Scale score of 15–18 indicates mild risk; a score of 14 falls in the mild-to-moderate risk range requiring preventive measures.
Question 7: An RPN observes that a client's surgical wound has red, warm, swollen edges with purulent drainage. The PRIMARY nursing diagnosis is:
- Impaired skin integrity related to surgical incision
- Risk for infection related to compromised immune function
- Infection related to wound contamination as evidenced by purulent drainage (Correct answer)
- Acute pain related to wound inflammation
Correct answer: Infection related to wound contamination as evidenced by purulent drainage
The presence of purulent drainage and signs of inflammation confirm an actual infection, making 'Infection' the most appropriate diagnosis.
RPN Client Assessment and Planning 4
A client with diabetes has a blood glucose of 52 mg/dL and is alert and oriented.
The RPN should FIRST: