Answers| LATEST, 2025/2026|With Correct Answers &
Rationale
1. A nurse is reviewing the techniques for transferring a client from a bed to a chair with
a group of assistive personnel (AP). Which of the following instructions should the nurse
include?
ANS: Use lower-body strength
RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a client to
reduce stress on the back
2. A nurse is participating in a quality improvement study about the effectiveness of
client pain management in the unit. Which of the following strategies should the nurse
use to collect data?
ANS: Review clients' charts for their rating of pain before pain medication was administered and
1 hr after administration
RATIONALE: The nurse should collect data from clients' charts about pain ratings before and
after pain management interventions
3. A nurse is reinforcing teaching about confidentiality with a client who has a new
diagnosis of HIV. Which of the following information should the nurse include in the
teaching?
ANS: "Your HIV status will be shared with members of your health care team."
RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare team
who provides direct care for the client, just like any other diagnoses
4. A nurse is planning care for a client who has a history of seizures. Which of the
following pieces of equipment should the nurse place in the client's room?
ANS: Suction catheter
RATIONALE: The nurse should place suction equipment in the room of a client who has a
history of seizures. During a seizure, the client might have excessive oral secretions or might
vomit. If the client's airway becomes occluded, then the nurse will need to suction the oral cavity
to maintain a patent airway
5. A nurse in a provider's office is reviewing the medical record of a client who requests a
prescription for an oral contraceptive. Which of the following findings should the nur
identify as a contraindication for oral contraceptive use?
ANS: Coronary artery disease
,RATIONALE: SCoronary Sartery Sdisease Sis Sa Scontraindication Sto Soral Scontraceptive Suse
Sbecause Sit Sincreases Sthe Sclient's Srisk Sfor Smyocardial Sinfarction. SOther Scontraindications Sfor
Sreceiving Soral Scontraceptives Sinclude Sgallbladder Sdisease, Sbreast Scancer, Sand
Shypertension\
6. A Snurse Sis Sassisting Swith Sthe Scare Sof Sa Sschool-age Schild Simmediately Sfollowing
Ssurgery. SThe Schild Sweighs S21.8 Skg S(48 Slb) Sand Shas Sa Schest Stube Sapplied Sto
Ssuction. SWhich Sof Sthe Sfollowing Sfindings Sshould Sthe Snurse Sreport Sto Sthe Sprovider?
ANS: S250 SmL Sof Ssanguineous Sdrainage Sover Sthe Slast S3 Shr
RATIONALE: SThe Snurse Sshould Srecognize Sthat Sif Smore Sthan S3 SmL/kg/her Sof Ssanguineous
Sdrainage Soccurs Sfor Smore Sthan S3 Sconsecutive Shours Sfollowing Ssurgery, Sit Scan Sindicate
Sactive Shemorrhaging. STherefore, S250 SmL Sof Ssanguineous Sdrainage Sfrom Sthe Schild's Schest
Stube Sis Sexcessive Sand Sthe Snurse Sshould Sreport Sthis Sfinding Sto Sthe Sprovider Simmediately
7. A Snurse Sis Scollecting Sdata Sfrom Sa Sclient Swho Sis Sat S30 Sweeks Sof Sgestation
Sand Shas Sgestational Sdiabetes. SWhich Sof Sthe Sfollowing Sfindings Sshould Sthe
Snurse Sreport Sto Sthe Sprovider Sas San Sindication Sof Shyperglycemia?
ANS: SPolyuria
RATIONALE: SThe Snurse Sshould Sidentify Spolyuria Sas San Sexpected Sfinding Sof Shyperglycemia
Sand Sreport Sthis Sfinding Sto Sthe Sprovider
8. A Snurse Sis Sdiscussing Shome Ssafety Swith Sa Sgroup Sof Sclients Swho Shave Stype S1
Sdiabetes Smellitus. SWhich Sof Sthe Sfollowing Sclient Sstatements Sindicates San
Sunderstanding Sof Sthe Steaching?
ANS: S"I Swill Sdispose Sof Smy Sneedles Sin Sa Splastic Slaundry Sdetergent Scontainer."
RATIONALE: SThe Snurse Sshould Sinstruct Sthe Sclient Sto Sdispose Sof Sneedles Sin Sa Spuncture-proof
Scontainer, Ssuch Sas Sa Splastic Slaundry Sdetergent Scontainer.
9. A Snurse Sis Scaring Sfor Sa Sclient Swho Shas SAlzheimer's Sdisease. SWhich Sof Sthe
Sfollowing Sactions Sshould Sthe Snurse Stake?
ANS: SEncourage Sthe Sclient Sto Sreminisce Sabout Sthe Spast
RATIONALE: SThe Sclient Swho Shas SAlzheimer's Sdisease Shas Sprogressive Sloss Sof Sshort-term
Smemory Sand Smight Snot Sbe Sable Sto Srecall Srecent Shappenings Sand Sevents. SThis Scan Slead
Sto Sincreased Sfrustration. SHowever, Sremote Smemory Sremains Sin Splace Sfor Sa Slonger Speriod Sof
Stime Sand Scan Selicit Sfeelings Sof Shappiness
10. A Snurse Sis Smonitoring Sa Sclient Swho Sis Sreceiving Stelemetry. SWhich Sof Sthe
Sfollowing SECG Sfindings Sshould Sthe Snurse Sreport Sto Sthe Sprovider?
ANS: SPR Sinterval S0.24 Sseconds
RATIONALE: SAn Sexpected SPR Sinterval Sis S0.12 Sto S0.20 Sseconds. SA Sprolonged SPR Sinterval
Sindicates Sa Sheart Sblock; Stherefore, Sthe Snurse Sshould Sreport Sthis Sfinding Sprovider
11. A Snurse Son Sa Smedical Sunit Sis Sreviewing Sa Sclient's Smedical Srecord. SWhich Sof Sthe
,following Sprocedures Sshould Sthe Snurse Sidentify Srequires Sthe Sclient Sto Ssign Sa Sseparate
Sinformed Sconsent Sform?
ANS: SLumbar Spuncture
RATIONALE: SThe Snurse Sshould Sidentify Sthat Sa Sclient Sneeds Sto Sprovide Sconsent Sfor
Sgeneral Streatment, Sas Swell Sas Sa Sseparate Swritten, Sinformed Sconsent Sfor Sany Streatment Sthat
Shas San Selement Sof Srisk, Ssuch Sas Sa Slumbar Spuncture
12. A Slicensed Spractical Snurse S(LPN) Sis Sreviewing Sclient Sassignments Sfor Sthe
Supcoming Sshift. SWhich Sof Sthe Sfollowing Sclients Sshould Sthe SLPN Sask Sthe Scharge
Snurse Sto Sreassign Sto Sa Sregistered Snurse S(RN)?
ANS: SA Sclient Swho Shas Sa Snew Scolostomy Sand Srequires Sthe Sdevelopment Sof Sa Steaching
Splan SRATIONALE: SDeveloping Sa Sclient Steaching Splan Sis Snot Swithin Sthe Sscope Sof Spractice
Sfor San SLPN. SThe Snurse Sshould Scontact Sthe Snursing Ssupervisor Sto Sinform Sthem Sof Sthe
Sclient's Sneed Sfor Sa Steaching Splan Sregarding Sthe Snew Scolostomy Sand Srequest Sthat Sthis
Sclient Sis Sreassigned Sto San SRN. SThe Sscope Sof Spractice Sof San SLPN Sdoes Sallow Sthe Snurse
Sto Sreinforce Steaching Sonce Sthe Splan Shas Sbeen Sestablished
13. A Snurse Sis Scaring Sfor Sa Sclient Swho Sis Srecovering Sfrom Sa Sstroke Sand Sis
Sexperiencing Sdifficulty Susing Seating Sutensils. SThe Snurse Sshould Sidentify Sthe Sneed
Sfor Sa Sreferral Sto Sone Sof Sthe Sfollowing Sinterprofessional Steam Smembers?
ANS: SOccupational Stherapist
RATIONALE: SThe Snurse Sshould Sidentify Sthe Sneed Sfor Sa Sreferral Sto San Soccupational
Stherapist Sto Steach Sthe Sclient Show Sto Suse Sspecial Seating Sutensils
14. A Snurse Sis Spreparing Sto Sperform Sblood Sglucose Smonitoring Sfor Sa Sclient Swho
Shas Stype S1diabetes SMellitus. SWhich Sof Sthe Sfollowing Sactions Sshould Sthe Snurse
Stake Sfirst?
ANS: SHold Sthe Sfinger Sfor Stesting Sin Sa Sdependent Sposition
RATIONALE: SEvidence-based Spractice Sindicates Sthat Sthe Snurse Sshould Sfirst Sposition Sthe
Stesting Ssite Sto Senhance Sblood Sflow, Swhich Simproves Sthe Sability Sto Scollect San Sadequate
Sspecimen
15. A Shome Shealth Snurse Sis Sreinforcing Steaching Swith Sa Sclient Sabout Sthe Suse Sof
Selastic Sstockings Sto Sdecrease Speripheral Sedema. SWhich Sof Sthe Sfollowing
Sinstructions Sshould Sthe Snurse Sinclude?
ANS: SApply Sthe Sstockings Sin Sthe Smorning
RATIONALE: SThe Snurse Sshould Sinstruct Sthe Sclient Sto Sapply Sthe Selastic Sstockings Sin Sthe
Smorning Sand Sremove Sthem Sat Sthe Send Sof Sthe Sday Sbefore Sbedtime
16. A Snurse Sin Sa Sprovider's Soffice Sis Sreviewing Spediculosis Scapitis Smanagement
, Sand GSprevention GSstrategies GSwith GSthe GSparent GSof GSa GSschool-age GSchild.
GSWhich GSof GSthe GSfollowing GSstrategies GSshould GSthe GSnurse GSinclude?
(Select GSall GSthat
GSapply.) GSANS:
Store GSthe GSchild's GSclothing GSin GSa GSseparate GScubicle GSwhen GSat GSschool.
Boil GSbrushes GSand GScombs GSin GSwater GSfor GS10 GSmin.
Dry GSbed GSlinens GSand GSclothing GSin GSa GShot GSdryer GSfor GSat
GSleast GS20 GSmin. GSRATIONALE:
Transmission GSof GSlice GSoccurs GSvia GScontact GSwith GSpersonal GSitems. GSBoiling GShair GScare
GSitems GSin GShot GSwater GSfor GS10 GSmin GSkills GSlice GSand GSnits. GSExposing GSbedding GSand
GSclothing GSto GSprolonged GSheat GSby GSwashing GSin GShot GSdryer GSfor GSat GSleast GS20 GSmin GSis
GSan GSappropriate GSstrategy
17. A GSnurse GSis GScontributing GSto GSthe GSplan GSof GScare GSfor GSa GSclient GSwho GShas GSa
GScontinent GSurinary GSdiversion. GSWhich GSof GSthe GSfollowing GSinterventions GSshould
GSthe GSnurse GSplan GSto GSimplement GSto GSfacilitate GSurinary GSelimination?
ANS: GSUse GSintermittent GSurinary GScatheterization GSfor GSthe GSclient GSon GSat GSregular
GSintervals GSRATIONALE: GSA GScontinent GSurinary GSdiversion GScontains GSvalves GSthat
GSprevent GSurine GSfrom GSexiting GSthe GSpouch; GStherefore, GSthe GSnurse GSshould GSplan GSto
GSinsert GSa GSurinary GScatheter GSat GSregular GSintervals GSto GSdrain GSurine GSfrom GSthe GSclient's
GSpouch.
18. A GSnurse GSis GSpreparing GSto GSperform GSa GSbladder GSscan GSfor GSa GSclient. GSWhich
GSof GSthe GSfollowing GSactions GSshould GSthe GSnurse GStake?
ANS: GSTell GSthe GSclient GSthey GSshould GSnot GSexperience GSany GSdiscomfort
RATIONALE: GSThe GSnurse GSapplies GSthe GShandheld GSscanner GSover GSthe GSarea GSof GSthe
GSbladder GSwhen GSperforming GSa GSbladder GSscan. GSThis GSnoninvasive GSprocedure GSshould
GSnot GScause GSthe GSclient GSany GSdiscomfort
19. A GSnurse GSis GScaring GSfor GSa GSclient GSwho GSis GScrying GSand GSstates GSthat GStheir
GSprovider GSinformed GSthem GSthat GSthey GShave GSa GStumor GSand GSwill GSneed GSa
GSbiopsy. GSWhich GSof GSthe GSfollowing GSresponses GSshould GSthe GSnurse GSmake?
ANS: GS"What GShave GSyou GSdone GSto GShelp GSyourself GSget GSthrough GSstressful GSsituations
GSbefore?" GSRATIONALE: GSThis GSis GSa GStherapeutic GSresponse. GSThe GSnurse GSis GSaware GSthat
GSthe GSclient GSis GSunder GSstress GSand GSencourages GScomparison GSto GSinvestigate GSwhether
GSthey GShave GSexperience GSdealing GSwith GSa GSstressful GSsituation
20. A GSnurse GSis GScaring GSfor GSa GSnewborn GSwho GSis GS12 GShr GSold. GSThe GSnurse
GSshould GSexpect GSthe GSnewborn's GSstool GSto GShave GSwhich GSof GSthe GSfollowing
GScharacteristics GSwithin GSthe GSfirst GS24 GShour GSfollowing GSbirth?