EXAM UPDATE 2026
QUESTIONA nurse is preparing to reinforce discharge teaching
with a client who speaks a different language than the nurse. The
client has a new diagnosis of diabetes mellitus and their partner is
at the bedside. Which of the following actions should the nurse
take? - answer-Contact an interpreting service via telephone to
assist with the instructions.
QUESTIONA nurse enters a client's room at the beginning of a
shift. Which of the following findings requires intervention by the
nurse? - answer-A capped bottle of sterile water that was opened
36 hr ago
A nurse is assisting with the care for a client on a medical surgical
unit.
Exhibit 1
Nurses' Notes
1000:Client admitted to unit from the emergency department for a
right hip fracture following a fall. Leg is currently splinted and
client is scheduled for surgery at 1400.1100:Provider met with
client to review informed consent. - answer-When taking actions,
the nurse should notify the nurse manager of the problem,
followed by completing a facility incident report. When ethical or
potential legal occurrences occur, the nurse should report the
occurrence to their nurse manager, facility administrator, or a risk
manager. The nurse should follow facility guidelines in completing
the incident report.
QUESTIONA nurse is assisting in the care of a client.
, Exhibit 1
Exhibit 2
Exhibit 3
Nurses' NotesDay 1, 0915:Client presents to ED with reports of
headache with sensitivity to light that started yesterday. Client
states, "I have had muscle aches too." The client is alert and
oriented to person, place, and time. Lung sounds are clear to
auscultation bilaterally. S1, S2 auscultated no murmur detected.
Rates pain as a 5 on a pain scale of 0 to 10. Obtained labs and
sent.Day 1, 1045:Nurse enters client's room. Client states "My
head is killing me and my neck is stiff and hurts too!" Client is
diaphoretic. Client is confused at times, states "I need to go in the
kitchen and get something to drink." Client rates pain as a 8 on a
pain scale of 0 to 10. Pain medication given as prescribed.
Provider notified. - answer-When using the urgent versus non-
urgent plan of care to prioritize hypothesis for the client care, the
PN should collaborate with charge nurse and recommend
addressing the client's WBC count, orientation status
temperature, respiratory rate, and pain rate. The client's WBC
count and temperature are above the expected reference range
and could indicate infection. The client orientation status has
changed, which requires further evaluation. The client's pain rate
has increased, which requires prompt intervention by the nurse.
The client's respiratory rate has also increased, which requires
further evaluation by the nurse.
QUESTIONA charge nurse is asked by two staff nurses to assist
in resolving a conflict about holiday scheduling. Which of the
following actions should the charge nurse take? - answer-
Encourage each staff nurse to give up something as part of the
negotiation.