2025; With Complete 180 Questions From Past Actual
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A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
A. Swaddle the newborn with this leg extended.
B. Maintain eye contact with the newborn during feedings.
C. Minimize noise in the newborn environment
D. Administer naloxone to the newborn - answers :C. Minimize noise in the newborn
environment
● Reduce environmental stimuli (decrease lights, lower noise level).
A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the
following is an activity a nurse should engage in to assist in disaster preparedness?
A. Participate in community drills and mock events.
B. Vaccinate susceptible children and adults against smallpox
C. Assess types, levels and scopes of disasters.
D. Make quarantine preparations for those exposed to anthrax Rationale: Assess First - answers
:A. Participate in community drills and mock events.
,A nurse is obtaining a client's medical history before initiating 1000 ml of 0.9% NaCl with 20
mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the
client receiving this IV solution?
A. Severe renal impairment. (Stage IV Kidney Disease)
B. Chronic alcohol use disorder
C. Multiple sclerosis
D. Advanced cardiac disease. - answers :A. Severe renal impairment. (Stage IV Kidney Disease)
A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a
soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space.
Which of the following is an appropriate documentation of the findings?
a. Fourth heart sound at the aortic area
b. Murmur at the mitral area
c. Third heart sound at the tricuspid area
d. Pericardial friction rub at the pulmonic area - answers :b. Murmur at the mitral area
A nurse is teaching a client who has a newly documented latex allergy. Which of the following
statements by the clients indicates an understanding of the teaching?
a. I will remove dairy products from my diet
b. I will remove peanuts from my diet
c. I will remove bananas from my diet
d. I will remove gluten from my diet - answers :c. I will remove bananas from my diet
,****People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum,
strawberry, tomato
A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes
mellitus. The nurse should report which of the following conditions is a contraindication for the
use of metformin?
a. Seizure disorder
b. Polycystic ovary syndrome
c. Renal insufficiency
d. Gluten intolerance - answers :c. Renal insufficiency
A nurse on a surgical pediatric care unit receives report prior to providing care for a group of
clients. Which of the following clients should the nurse assess first?
a. A 15 year old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site
b. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120
c. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate
d. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent
swallowing - answers :d. 8 year old client who is 12 hr postop following a tonsillectomy and is
experiencing frequent swallowing - bleeding
A nurse is teaching a client how to perform kegel exercises. Which of the following client
statements indicates understanding of the teaching?
a. I will alternately contract and relax my gluteal muscles
b. I will perform the exercises once each day before bed
c. I will try to hold my urine for a little after i first feel the urge to urinate
, d. I will determine which muscles to contract by stopping and starting my stream of urine -
answers :d. I will determine which muscles to contract by stopping and starting my stream of
urine
A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which
of the following statements indicates that the client understands the teaching?
a. I need to have an enema before the test
b. I should urinate before the test
c. I will lie on my left side during the test
d. I will drink an oral glucose solution during the test - answers :a. I need to have an enema
before the test
A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago.
Which of the following findings should the nurse expect?
a. Memory loss
b. Slurred speech
c. Elevated temperature
d. hypotension - answers :c. Elevated temperature
***● Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension
A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the
following clinical manifestations is an expected finding for this client?
a. Report of occipital headache
b. Scratchy, high pitched sound upon chest auscultation