2025-2026 QUESTIONS AND ANSWERS
COMPLETE SOLUTION
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of
the following information should the nurse include in the teaching?
a) Assign the client to a room with a negative air-flow system
b) Use alcohol-based hand sanitizer when leaving the clients room
c) clean contaminated surfaces in the clients room with a phenol solution
d) have family members wear a gown and gloves when visiting - D
A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the
client has developed phlebitis and removes the IV catheter. Which of the following actions should the
nurse take next?
a) place a warm compress over the IV site
b) record the findings in the client's chart
c) notify the client's primary care provider
d) prepare to insert a new IV catheter - A
A nurse is caring for a client who has dementia. Which of the following interventions
should the nurse take to minimize the risk for injury for this client?
a) use a bed exit alarm system
b) raise 4 side rails while client is in bed
c) apply one soft wrist restraint
d) dim the lights in the client's room - A
,A nurse is implementing a plan of care for a client who is at risk for falls. Which of the
following is an appropriate nursing action?
a) implement a regular toileting schedule
b) encourage the client to wear athletic socks when ambulating
c) place all 4 bed rails in the upright position
c) require a family member to remain at the bedside - A
Which of the following techniques should the nurse use when performing nasotracheal
suctioning for a client?
a) insert the suction catheter while the client is swallowing
b) apply intermittent suction when withdrawing the catheter
c) place the catheter in a location that is clean and dry for later use
d) hold the suction catheter with the clean, non-dominant hand - B
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that
providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the
nurse implement to promote the client's independence?
a) request an occupational therapy consult to determine the need for assistive devices
b) assign assistive personnel to perform self-care tasks for client
c) instruct the client to focus on gradually resuming self-care tasks
d) ask the client if a family member is available to assist with his care - C
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of
the following is an expected finding?
a) serum albumin level of 3 g/dL
,b) HDL level of 90 mg/dL
c) Norton scale score of 18
d) Braden scale score of 20 - A
A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the
following client statements indicates an understanding of the procedure?
a) "I had a bowel movement, but I was able to save the urine"
b) "I have a specimen in the bathroom from about 30 minutes ago"
c) "I flushed what I urinated at 7 am and have saved the rest since"
d) "I drink a lot, so I will fill up the bottle and complete the test quickly" - C
A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following
should be used to irrigate the tube in order to maintain fluid and electrolyte balance?
a) tap water
b) sterile water
c) 0.9% sodium chloride
d) 0.45% sodium chloride - C
A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg
weakness. Which of the following should the nurse include in the teaching?
a) use the cane on the weak side of the body
b) advance the cane and the atrong leg simultaneously
c) maintain two points of support on the floor
d) advance the cane 30 to 45 cm (12-18 in) with each step - C
, Which of the following should indicate to a nurse the need to suction a client's
tracheostomy?
a) irritability
b) hypotension
c) flushing
d) bradycardia - A
A nurse is caring for a client who has a prescription for wound irrigation. Which of the
following actions should the nurse take?
a) wear sterile gloves when removing the old dressing
b) warm the irrigation solution to 40.5C (105F)
c) cleanse the wound from the center outwards
d) use a 20 mL syringe to irrigate the wound - C
A nurse is providing teaching about a clear liquid diet. Which of the following should the
nurse instruct the client to avoid?
a) lemon-lime sports drinks
b) ginger ale
c) black coffee
d) orange sherbet - D
A nurse is caring for a client who is having difficulty voiding following the removal in an
indwelling urinary catheter. Which of the following interventions should the nurse take?
a) assess for bladder distention after 6 hr
b) encourage the client to use a bed pan in the supine position