ANSWERS 2025
A female client presents in the emergency department and tells the
nurseraped
was that she
last night. Which question is most important for the
nurse
A. Hasto sheask?
taken a bath since the rape
B. Is the place where she lives a safe
occurred?
place?
C. Does she know the person who
raped
D. Did her?
she report the rape to the police department? ( correct
answers
taken ) A.since
a bath Has she
the rape
occurred?
The nurse is completing the admission assessment of a 3-year old who
is admitted
with bacterial meningitis and hydrocephalus. Which assessment finding
is evidence
that the child is experiencing increased intracranial
pressure
A. Tachycardia
(ICP)? and
B. Sluggish and unequal pupillary
tachypnea
C. Increased head circumference and bulging
responses
D. Blood pressure fluctuations and syncope
fontanels ( correct answers ) B.
Sluggish pupillary
unequal and
responses
A client with acute pancreatitis is admitted with severe, piercing abdominal
pain and serum
elevated an amylase. Which additional information is the client
most likely
report to theto
A. Abdominal pain decreases when lying
nurse?
B. Pain lasts an hour and leaves the abdomen
supine
C. Right upper quadrant pain refers to right
tender
D. Drinks alcohol until intoxicated at least twice weekly.
scapula ( correct
answers ) pain
Abdominal A. decreases when lying
supine
A child newly diagnosed with sickle cell anemia (SCA) is being
discharged
hospital. frominformation
Which the is most important for the nurse to provide
the parents
prior to
discharge?
A. Instructions about how much fluid the child should
drink
B. daily.
Signs of addiction to opioid pain
medications
C. Information about non-pharmaceutical pain relief
measures
D. Referral for social services for the child and family ( correct
answers ) A.
Instructions about how much fluid the child should
drink daily
To auscultate for a carotid bruit, the nurse places the stethoscope at
what location.
(Select the location on the image with a red dot). ( correct answers )
I placed
red dot onthethe base of the neck on the
right side
,After receiving report on an inpatient acute care unit, which client
should the nurse
assess
A. The client with an obstruction of the large intestine who is
first?
experiencing abdominal
distentio
B. The client who had surgery yesterday and is experiencing a
n
paralytic
absent bowel
ileus with
C. The client with a small bowel obstruction who has a nasogastric
sounds
tube thatgreenish
draining is
D. The client with a bowel obstruction due to a volvulus who is
fluid
experiencing
rigidity ( correct
abdominal
answers ) D. The client with a bowel obstruction due to
a volvulus
who is experiencing abdominal rigidity
A teenager presents to the emergency department with palpitations after
vapingThe
party. at aclient is anxious, fearful, and hyperventilating. The nurse
anticipates
client developing
the which acid base
A. Respiratory
imbalance?
acidosis
B. Metabolic
alkalosis
C. Metabolic
D. Respiratory alkalosis( correct answers ) D. Respiratory alkalosis
acidosis
A client with dyspnea is being admitted to the medical unit. To best
prepare arrival,
client's for the the nurse should ensure that the client's bed is in
which position?
A.
Supine
B. supine; feet elevated higher
than
C. head head elevated higher
supine;
than feet ( correct answers ) Fowlers
D. Fowlers
The nurse is taking the blood pressure measurement of a client with
Parkinson's
disease. Which information in the client's admission assessment is
relevantplan
nurse's to the
for taking the blood pressure reading? (Select all
theFrequent
A. apply)
B. Occasional
syncope
C. Flat
nocturia
D. Blurred
affect
E. Frequent drooling( correct answers ) A. Frequent
vision
C. Flat
syncope
affect
D. Blurred vision
While caring for a client's postoperative dressing, the nurse
observes at
drainage purulent
the wound. Before reporting this finding to the healthcare
provider,
nurse the review which of the client's laboratory
should
values?
A. Serum
albumin
B. Culture for sensitive
organisms
C. Serum blood glucose
level
,D. Creatinine level ( correct answers ) B. Culture for
sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following
resuscitation from a near-drowning incident. While providing care to the
successful
child, the
nurse begins talking with his preadolescent brother who rescued the
child from the
swimming pool and initiated resuscitation. The nurse notices the older
boy becomes
withdrawn when asked about what happened. Which action should the
nurse
A. Develop
take? a water safety teaching plan for
theAsk
B. family
the older brother how he felt during the
C. Tell the older brother that he seems
incident
D. Commend the older brother for his heroic actions ( correct answers )
depressed
B. Askbrother
older the how he felt during the
incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse
that he
been soaking
has in hot baths at night with no relief of his discomfort. Which
action
the nurse
should
take?
A. Encourage the client to use cooler water and apply calamine lotion
after
B. soaking
Obtain a PRN prescription for an analgesic that the client can use for
symptom
C. Suggestrelief
that the client take brief showers and apply oil-based
lotion after
showerin
D. Explain that the symptoms are caused by liver damage and cannot be
g
relievedanswers ) A. Encourage the client to use cooler water and
correct (
apply calamine
lotion after
soaking
An older client with a long history of coronary artery disease (CAD),
hypertension
(HTN), and heart failure (HF) arrives in the Emergency Department (ED) in
respiratory
distress. The healthcare provider prescribes furosemide IV. Which
therapeutic
response to furosemide should the nurse expected in the client with
acute
A. Increased
HF? cardiac
B. Reduced
contractility
C. Relaxed vascular
preload
D. Decreased afterload ( correct answers ) B. Reduced
tone
preload
Which intervention should the nurse include in the plan of care for
a child with
tetanus
A. Encourage coughing and deep
?
B. Minimize the amount of stimuli in
breathing
theReposition
C. room from side to side
every
D. Openhour
window shades to provide natural light ( correct answers )
B. Minimize
amount the
of stimuli in the
room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the
age of 9, to
admitted is the hospital in diabetic ketoacidosis. Which occurrence is the
most likely
cause of the
ketoacidosis?
, A. Ate an extra peanut butter sandwich before
gym
B. incorrectly
class administered too much
C. Had a cold and ear infection for the past
insulin
twoSkipped
D. days eating lunch ( correct answers ) C. Had a cold and ear
infection
past two for
days
the
A client with a prescription for "do not resuscitate" (DNR) begins to
manifest signs
impending of After notifying the family of the client's status, what
death.
priority the
should action
nurse
A. The impending signs of death should be
implement?
B. The client's status should be conveyed to the
documented
C. The client's need for pain medication should be
chaplain
D. The nurse manager should be updated on the client's status ( correct
determined
answers
C. The client's
) need for pain medication should be determined
Which self care measure is most important for the nurse to include in the
plan
of of care
a client recently diagnosed with type 2 diabetes
mellitus?
A. Self-injection
techniques
B. Blood glucose
monitoring
C. Diabetic diet meal
planning
D. A realistic exercise plan ( correct answers ) B. Blood glucose
monitoring
A client who gave birth 48 hours ago has decided to bottle feed the
infant. Duringthe
assessment, thenurse observes that both breasts are swollen, warm, and
tender on
palpation. Which instruction should the nurse
provide?
A. Apply ice to the breasts for
comfort
B. Wear a loose-fitting bra during the day to prevent nipple
irritation
C. Run warm water over
D. Express small amounts of milk from the breasts to relieve pressure (
breasts
answers ) A. Apply ice to the breasts for comfort
correct
The nurse is preparing a client who had a below-the-knee (BKA)
amputation
discharge tofor
home. Which recommendations should the nurse provide
this client?
(Select all that
A. Avoid range of motion
apply)
B. Use a residual limb
exercises
C. Apply alcohol to the stump after
shrinker
D. Inspect skin for
bathing
E. Wash the stump with soap and water ( correct answers ) B. Use a
redness
residual limb
shrinke
rD. Inspect skin for
redness
E. Wash the stump with soap and
water