Form B | Questions and Answers |
LATEST, 2024/ 2025
1. A nurse is caring for a client who is 4 hr postoperative ff a total thyroidectomy.
Which of the ff manifestations should the nurse report to the provider as
indicating possible hypocalcemia?
ANS: Tingling of fingers
2. A nurse in a long-term care facility is assisting with an in-service for newly hired
assistive personnel about legal issues within the facility. Which of the ff should
the nurse include as an example of assault?
ANS: Informing a client the nurse is going to administer an injection even though
the client refuses
.
3. A nurse is collecting data from who is severe pain. Which of the ff questions
should the nurse ask first?
ANS: "Where is your pain located?"
4. A nurse is reviewing the laboratory results for a client who is at 29 weeks
gestation. For which of the ff results should the nurse notify the provider? ANS:
Platelet count 95,000 mm3
5. A nurse is performing a dressing change for a client who had abdominal surgery 5
days ago. The nurse notes organs protruding from the incision. Which of the ff
actions should the nurse take?
ANS: Cover the exposed area with sterile, saline-soaked dressings.
6. A nurse is speaking with the adult daughter of a client who has Alzheimer's
disease. The daughter states, "I love my dad, but caring for him is wearing me
out." Which of the ff response should the nurse make?
ANS: "Let's discuss how caring for your father is affecting your health.
7. A nurse is contributing to the plan of care for a care for a client who has chest
tube connected to a closed drainage system. Which of the ff actions should the
nurse include in the plan of care?
ANS: Maintain the drainage system below the level of the client's chest.
8. A nurse in an acute mental health facility is caring for a client who has borderline
personality disorder and reports. "I am going to kill my girlfriend when I get out
of here." Which of the ff actions should the nurse take?
, ANS: Notify the client's care team of the threats against the partner
9. A nurse is admitting a client who is at high risk for suicide. Which of the ff
actions is the nurse's priority?
ANS: Search the client's personal belongings
10. A nurse is caring for a client who is 1 day postoperative and is unable to
ambulate. Which of the ff actions should the nurse take to promote the client's
venous return? ANS: Maintain the sequential compression device.
11. A nurse in a pediatric clinic is collecting the data from a school-age child whose
injuries are inconsistent with the parent's stated cause. Which of the ff actions
should the nurse take?
ANS: Report the suspected abuse to a appropriate agency.
12. A nurse is collecting data from a middle adult female client who is taking
melatonin. Which of the ff responses to the med should the nurse expect? ANS:
Improved sleep
13. A nurse on a pediatric unit is collecting data from four newly admitted clients.
Which of the ff clients should the nurse identify as being at risk for urinary
retention?
ANS: A school-age child who has allergic rhinitis and is taking diphenhydramine.
14. A nurse is preparing to administer purified protein derivative (PPD) to a client
who has suspected TB. Which of the ff actions should the nurse plan to take?
ANS: Ensure the injection produces a wheal on the skin
15. A client who is diagnosed with Parkinson's disease verbalizes frustration due to
increase difficulty with ambulation. Which of the ff responses should the nurse
take? ANS: Perform active ROM with your arms and legs two times a day.
16. a Nurse is collecting data from a client who has multiple fractures following a
motorvehicle crash. For which of the following client statements
ANS: "I am so frustrated. I cannot even open my milk carton for breakfast."
17. A nurse on an acute care unity is collecting data from a school-age Child who has
cystic fibrosis. Which of the following findings is the priority for the nurse? ANS:
Reports lack of appetite
18. a nurse working in a provider's office receives a phone call from the parent of a
schoolage child who has varicella. The parent asked the nurse when the child can
return to school. Which of the following responses should the nurse make?
ANS: "When the lesions have scabbed over."
, 19. A nurse is caring for a client who has a Penrose drain. To ensure proper placement
and functioning of the drain, which of the following should the nurse expect to
observe?
ANS: The safety pin is present at the distal end of the drain.
20. A community health nurse is helping to reinforce teaching about hepatitis A with
a group of employees at a childcare facility. Which of the following
characteristics should the nurse identify as an external factor that can impede
learning for the participants? ANS: Poor lighting in the learning setting
21. A nurse is observing newly licensed nurse who is providing tracheostomy care for
a client. The nurse identifies proper performance of the procedure when the newly
licensed nurse selects which of the following solutions to clean the inner cannula?
ANS: Hydrogen peroxide
22. A nurse is caring for a client who has right sided heart failure. The client's partner
expresses concern the the client will die. Which of the following responses should
the nurse make?
ANS: "It is difficult to see someone so sick. What have you been told about your
partner's prognosis?"
23. A nurse is reinforcing discharge instructions with the parent of an infant who has
rotavirus. which of the following statements by the parent indicates an
understanding of the teaching?
ANS: "I will apply diaper cream to my baby's skin during each diaper change."
24. A nurse is caring for a client who is scheduled for surgery in the morning. The
nurse learns that the client has decided not to have surgery even though he has
already signed the informed consent form. Which of the following actions should
the nurse take? ANS: Report the situation to the provider who obtained the
informed consent.
25. A nurse has to administer medications to a group of clients. For which of the
following client situations should the nurse complete and incident report?
ANS: The nurse administered insulin lispro to a client who has diabetes mellitus and
is
NPO.
26. a nurse is collecting data from a client who is experiencing a situational crisis
following the loss of a job. The client states, I don't think I can go through this
again. Which of the following actions is the nurse's priority?
ANS: Determine if the client is experiencing psychotic thinking.
27. A nurse is reinforcing discharge teaching with a client who is 48 hr post op from a
mastectomy. Which of the following statements by the client indicates an
understanding of the teaching?