answers 2025\2026 A+ Grade
The nurse and the licensed practical nurse (LPN/LVN) provide care to clients on the medical floor. Which
task can the nurse delegate to the LPN/LVN?
1. Teach the client colostomy care.
2. Add a nursing diagnosis to the nursing care plan.
3. Administer a tap-water enema.
4. Add potassium to an existing IV infusion.
- correct answer 3. Administer a tap-water enema.
The LPN/LVN performs basic skills. Administration of a tap-water enema falls under the category of a
basic skill. Licensed practical or vocational nurses (LPN/LVNs) assist with implementation of defined
plans of care, perform procedures according to protocol, differentiate normal from abnormal, care for
physiologically stable clients with predictable conditions, has knowledge of asepsis and dressing
changes. Ability to administer medications varies with educational background and state nurse practice
act.
A two day postoperative client reports pain, tenderness, and redness of the right calf. Which findings are
most critical for the nurse to report to the health care provider?
1. Nausea and abdominal distention.
2. Back pain and hematuria.
3. Chest pain and shortness of breath.
4. Mild redness around the surgical incision.
- correct answer 3. Chest pain and shortness of breath.
Calf pain suggests the client may have a venous thromboembolism (VTE). The most serious
complications of VTE is pulmonary embolism (PE). If the client is having chest pain and shortness of
breath, these findings need to be reported to a health care provider immediately.
, The nurse instructs a client how to successfully begin a regular exercise program. The nurse determines
teaching is successful if the client makes which statement?
1. "I should start by running 5 miles every day."
2. "I will exercise for a few minutes twice a week."
3. "I should focus on aerobic exercise."
4. "I am making a commitment to exercise regularly."
- correct answer 4. "I am making a commitment to exercise regularly."
The adult client should commit to daily exercise. The client must commit to exercise regularly, and
develop an exercise program that the client enjoys and one that fits into the lifestyle. It may be
beneficial for the client to exercise with a group to support the new habit.
The nurse knows which statement is an important fact about warfarin?
1. It has a prolonged action.
2. It is never given for prolonged periods of time.
3. It must be given several times a day to be effective.
4. It can only be given parenterally.
- correct answer 1. It has a prolonged action.
Warfarin has prolonged action. The duration is 2-5 days and the client should be taught that a risk of
bleeding continues for several days after the medication is discontinued.
The nurse provides care for a client on the medical surgical floor who is experiencing difficulty sleeping
at night. Which nursing action is most appropriate to promote adequate sleep for the client?
1. Encourage frequent daytime naps.
2. Ensure the room is cool.
3. Provide the client with hot tea at bedtime.