2026 FINAL PAPER EXAM Q&A STUDY GUIDE
WITH VERIFIED SOLUTIONS
◉ Which postmenopausal client's complaint should the nurse refer
to the healthcare provider?
A) Breasts feel lumpy when palpated.
B) History of white nipple discharge.
C) Episodes of vaginal bleeding.
D) Excessive diaphoresis occurs at night. Answer: C) Episodes of
vaginal bleeding.
Rationale: Postmenopausal vaginal bleeding (C) may be an
indication of endometrial cancer, which should be reported to the
healthcare provider. Compared to a new-onset of a single lump,
breasts that feel lumpy (A) overall may be a normal variant or a
finding consistent with nonmalignant fibrocystic disease. Up to 80%
of women experience (B), depending on sexual stimulation or
hormonal levels, and is no longer recommended as a reportable
symptom when discovered during breast self-exam (BSE). The client
may need further teaching concerning (D), a disturbing symptom,
but it is not as important as (C).
,◉ The nurse is assisting a client out of bed for the first time after
surgery. What action should the nurse do first?
A) Place a chair at a right angle to the bedside.
B) Encourage deep breathing prior to standing.
C) Help the client to sit and dangle legs on the side of the bed.
D) Allow the client to sit with the bed in a high Fowler's position.
Answer: D) Allow the client to sit with the bed in a high Fowler's
position.
Rationale: The first step is to raise the head of the bed to a high
Fowler's position (D), which allow venous return to compensate
from lying flat and vasodilating effects of perioperative drugs. (A, B,
and C) are implemented after (D).
◉ The nurse is receiving report from surgery about a client with a
penrose drain who is to be admitted to the postoperative unit.
Before choosing a room for this client, which information is most
important for the nurse to obtain?
A) If suctioning will be needed for drainage of the wound.
B) If the family would prefer a private or semi-private room.
C) If the client also has a Hemovac® in place.
,D) If the client's wound is infected. Answer: D) If the client's wound
is infected.
Rationale: Penrose drains provide a sinus tract or opening and are
often used to provide drainage of an abscess. The fact that the client
has a penrose drain should alert the nurse to the possibility that the
client is infected. To avoid contamination of another postoperative
client, it is most important to place an infected client in a private
room (D). A penrose drain does not require (A). Although (B) is
information that should be considered, it does not have the priority
of (D). (C) is used to drain fluid from a dead space and is not
important in choosing a room.
◉ A patient admitted for a head injusry develops dry skin and urine
output of 600 mL/hr. Which of the following interventions should
the nurse perform first?
a) Assess the patient's urine specific gravity
b) Slow IV fluid infusion rate
c) Assess the patient's level of conciousness
d) Notify the physician Answer: a) Assess the patient's urine specific
gravity
, Ratoinale: A urine output of 400 mL/hr after sustaining a head
injury may be indictative of diabetes insipidus. The nurse should
assess for low specific gravity and elevated serum osmolarity.
-Diabetes insipidus is the failure to produce antidiuretic hormone
due to damage to the pituitary gland from increased ICP.
-Notifying the physician is appropriate after the nurse has gathered
additional data.
◉ A patient is prescribed dexamethasone (Decadron) to reduce
cerebral edema after a motor vehicle accident. Which of the
following assessment findings should the nurse expect if this
treatment is effective?
a) Increased response to stimuli
b) decreased urine output
c) respiration rate of 12
d) Increased blood pressure Answer: a) Increased response to
stimuli
rationale: Dexamethasone (Decadron) is a corticosteroid that
reduces inflammation in the brain. When effectivness is achieved,
the patient's neurological status should improve.
-Decadron has little effect on blood pressure, respiration rate, and
urine output.