(2025/2026) UPDATED EXAM|
QUESTIONS WITH MULTIPLE
CHOICES |VERIFIED & REVISED
ANSWERS
1. A male client with stomach cancer returns to the
unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hour IV. One hour after
admission to the unit, the nurse notes 300 mL of
blood in the suction canister, the client's heart rate
is 155 beats/minute, and his blood pressure is
78/48 mmHg. In addition to reporting the finding to
the surgeon. Which action should the nurse
implement first?
- Answer-d. Increase the infusion rate of Lactated
Ringer's solution.
2. an adult male who fell 20 feet from the roof of
this home has multiple injuries, including a right
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,pneumothorax. Chest tubes were inserted in the
emergency department prior to his transfer to the
intensive care unit (ICU). the nurse notes that the
suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water
seal, and over the past hour 75 ml of bright red
blood is measured in the collection chamber. Which
intervention should the nurse implement?
- Answer-a. Add sterile water to the suction control
chamber.
3. A client who received hemodialysis yesterday is
experiencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate
36 breaths/minute. The client is manifesting
shortness of breath, bilateral 2+ pedal edema, and
an oxygen saturation on room air of 89%. Which
action should the nurse take first?
- Answer-c. Begin supplemental oxygen.
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,4. A client with Addison's crisis is admitted for
treatment with adrenal cortical supplementation.
Based on the client's admitting diagnosis, which
findings require immediate action by the nurse?
(Select all that apply) - Answer-Headache and
tremors
Irregular heart rate
pallor and diaphoresis
5. An older client is admitted with fluid volume
deficit and dehydration. Which assessment finding
is the best indicator of hydration that the nurse
should report to the healthcare provider?
- Answer-d. Skin tenting occurs when the client's
forearm is pinched.
6. After an inservice about electronic health record
(EHR) security and safeguarding client information,
the nurse observes a colleague going home with
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, printed copies of client information in a uniform
pocket. Which action should the nurse take?
- Answer-a. File a detailed incident report with the
specific hiring facility.
7. The nurse is evaluating a tertiary prevention
program for clients with cardiovascular disease
implemented in a rural health clinic. Which
outcome indicate the program is effective?
- Answer-c. Clients who incurred disease
complications promptly received rehabilitation.
8. The nurse is caring for a client with chronic
obstructive pulmonary disease (COPD) who uses
oxygen at 2 L/minute per nasal cannula
continuously. The nurse observes that the client is
having increased shortness of breath with
respirations at 23 breaths/minute. Which action
should the nurse implement first?
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