EXAM NEWEST 2025 COMPLETE
200 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED
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A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at
125 mL/hr has been started. One hour after the IV initiation the client begins screaming,
"I can't breathe!" The nursing priority action is:
1. Discontinue the IV site and contact the primary health care provider
2. Elevate the head of the bed and obtain vital signs
3. Contact the primary health care provider to obtain a prescription for a sedative
4. Assess for allergies and change the IV to an intermittent infusion device -
✔✔ANSWER✔✔>>Elevate the head of the bed and obtain vital signs
,A nurse is assessing a client with a diagnosis of early left ventricular heart failure.
Specific to this type of heart failure, the nurse expects the client to state:
1. "My ankles are swollen."
2. "I am tired at the end of the day."
3. "When I eat a large meal, I feel bloated."
4. "I have trouble breathing when I walk rapidly - ✔✔ANSWER✔✔>>4. "I have trouble
breathing when I walk rapidly
A client who had a myocardial infarction asks the nurse, "What's the chance of my
having another heart attack if I carefully watch my diet and stress levels?" What is the
nurse's most appropriate initial response?
1. Focus on the client's feelings by exploring the reason why the question was asked.
2. Explain that it is all right to be frightened and refer the client to the psychiatric nurse.
3. Provide information that the client is correct in being especially careful in these areas.
4. Suggest that the client discuss follow-up care with the health care provider and the
dietitian. - ✔✔ANSWER✔✔>>1. Focus on the client's feelings by exploring the reason
why the question was asked.
The nurse is assessing a client for signs of right ventricular failure. What should the
nurse expect if this occurs?
1. Slowed pulse rate
2. Pleural friction rub
3. Neck vein distention
4. Increasing hypotension - ✔✔ANSWER✔✔>>3. Neck vein distention
A client with bilateral varicose veins of the lower extremities questions the nurse about
the brownish discoloration of the lower legs. The best response by the nurse is, "This is
probably the result of:
1. Inadequate arterial blood supply."
2. Delayed healing of tissues after an injury."
,3. Increased production of melanin in the area."
4. Leakage of red blood cells through the vascular wall." - ✔✔ANSWER✔✔>>4.
Leakage of red blood cells through the vascular wall."
A client with arterial insufficiency of both lower extremities is visited by the home health
care nurse. An essential nursing intervention is to teach the client to:
1. Maintain elevation of both legs
2. Massage the legs when painful
3. Apply a hot water bottle to the legs
4. Check pulses in the legs regularly - ✔✔ANSWER✔✔>>4. Check pulses in the legs
regularly
A client is hospitalized for the treatment of thrombophlebitis. What should the nurse
include in the client's teaching plan related to how to prevent thrombophlebitis?
1. Perform leg exercises
2. Sit with the knees flexed
3. Apply warm soaks to the legs daily
4. Put on elastic stockings before arising - ✔✔ANSWER✔✔>>4. Put on elastic
stockings before arising
During chest physiotherapy (CPT), a client reports fatigue, and the client's heart rate
increases from 90 to 140 beats per minute. What should the nurse do next?
1. Interrupt the therapy.
2. Encourage deep breathing.
3. Place the client in the low-Fowler position.
4. Have the client complete the therapy before resting. - ✔✔ANSWER✔✔>>1. Interrupt
the therapy.
The nurse is providing teaching to a client with atrial flutter who has received a
prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods
that are high in Vitamin K and that should be avoided. What should the nurse include on
the list? (Select all that apply.)
, 1. Spinach
2. Oranges
3. Broccoli
4. Chicken breast
5 Sweet potatoes - ✔✔ANSWER✔✔>>1. Spinach
3. Broccoli
The nurse is planning nutritional education for a client with lower extremity arterial
disease (LEAD). What diet modifications should the nurse include?
1. Decreasing both fluid and sodium intake
2. Increasing both calcium and potassium intake
3. Increasing both vitamin E and refined grain intake
4. Decreasing both cholesterol and saturated fat intake - ✔✔ANSWER✔✔>>4.
Decreasing both cholesterol and saturated fat intake
A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an
occasional premature atrial contraction (PAC). What action should the nurse take?
1. Continue to monitor the client.
2. Notify the health care provider.
3. Ensure that a defibrillator is close by.
4. Administer lidocaine intravenously as per protocol. - ✔✔ANSWER✔✔>>1. Continue
to monitor the client.
After abdominal surgery a client suddenly reports numbness in the right leg and a
"funny feeling" in the toes. What should the nurse do first?
1. Elevate the legs and tell the client to drink more fluids.
2. Instruct the client to remain in bed and notify the health care provider.
3. Rub the client's legs to stimulate circulation and cover the client with a blanket.