QUESTIONS WITH 100% RATED CORRECT ANSWERS 2025 LATEST
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A young adult client, admitted to the emergency department following a motor vehicle
collision is receiving transfusion of 4 units of packed red blood cells (PRBC). The client's
pretransfusion hematocrit is 17% (0.17 volume). How many hematocrit value should the
nurse expect the client to have after all of the PRBCs have been transfused
Reference Range:
Hematocrit (42% to 52% (0.4Lto 0.52 volume fraction)]
A 9% (0.09 volume fraction).
B 39% (0.39 volume fraction).
C 19% (0.19 volume traction)
D 29% (0.29 volume fraction).
D 29% (0.29 volume fraction).
A female client on a psychiatric unit is sweating profusely while she vigorously does push-
ups and then runs the length of the corridor several times before crashing into furniture in
the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to
sit in. When another client objects to the disturbance, the client shouts, "I am the boss here.
I do what I want." Which nursing problem best supports these observations?
• A Disturbed personal identity related to grandiosity.
• B Risk for activity intolerance related to hyperactivity.
• C Risk for other related violence related to disruptive behavior.
• D Deficient diversional activity related to excess energy level.
• C Risk for other related violence related to disruptive behavior.
The antitubular drug isoniazid is prescribed for a client with active tuberculosis. To
evaluate the effectiveness of this medication, which outcome can the nurse expect this client
to exhibit?
A Decreased appetite and weight loss.
B A positive sputum smear and culture.
C Decreased cough and sputum.
D Vertigo and tinnitus.
C Decreased cough and sputum.
5 The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires
the nurse to intervene?
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• A Crying for more than 10 minutes.
• B Acrocyanosis with hands and feet cool to touch.
• C Respiratory rate of 73 breaths/minute.
• D No voiding or stooling since birth.
• C Respiratory rate of 73 breaths/minute.
→ infant is hyperventilating; should be 30-60 breaths/min
A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange
from a respiratory infection. Which assessment finding warrants immediate intervention
by the nurse?
• A Diminished lung sounds.
• B Generalized weakness.
• C Elevated temperature.
• D Pain when swallowing.
• A Diminished lung sounds.
A client who is terminally ill has an advance directive that stipulates no resuscitative
measures are to be taken. The client's death is imminent and the family is in the client's
room. The client is currently exhibiting Cheyne-Stokes respirations and has a blood
pressure of 60/30 mm Hg. Which is the priority nursing action?
• A Allow privacy for the family and client to express their feelings to one another.
• B. Elevate the head of the client's bed and apply oxygen using a face mask.
• C Apply an automatic blood pressure cuff and take readings every 15 minutes.
• D Teach the client's family how to use an oral suction device to clear the airway.
• A Allow privacy for the family and client to express their feelings to one another.
A client with cirrhosis has ascites and reports feeling short of breath. The client is in a
Semi-Fowler's position with arms posit Which action should the nurse implement?
A Reposition the client in a side-lying position and support his abdomen with pillows.
B Raise the head of the bed to a Fowler's position and support his arms with a pillow.
C Place the client in a shock position and monitor his vital signs at frequent intervals.
D. Elevate the client's feet on a pillow while keeping the head of the bed elevated.
B Raise the head of the bed to a Fowler's position and support his arms with a pillow.
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A school-aged child is admitted with status asthmaticus. The child is receiving oxygen at 4
liters/minute per nasal cannula, but remains dyspneic and is extremely anxious. Which
intervention should the nurse implement?
• A Administer an as needed (PRN) anxiolytic.
• B Orient the child to the hospital unit.
• C Talk to child while holding the child's hand.
D Encourage intake of oral fluids.
• C Talk to child while holding the child's hand.
The nurse is caring for a 3-year-old child who has been recently diagnosed with cystic
fibrosis. Which discharge instruction by the nurse is most important to promote pulmonary
function?
• A Cough suppressants can be used up to four times a day for relief. (Do not suppress the
cough, you want the patient to cough up thick secretions)
• B. Chest physiotherapy should be performed before meals and at bedtime.
C Oxygen should be given through a nasal cannula between 4 to 6 L/min. (be cautious
because many patients with CF have chronic carbon dioxide retention. Unsupervised use of
oxygen can be harmful)
D Exercise is discouraged in order to preserve pulmonary vital capacity. (Exercise should
be encouraged)
• B. Chest physiotherapy should be performed before meals and at bedtime.
An older adult resident of a long-term care facility is walking in the hallway and stops to
show the nurse small bruises that recently appeared on the tops of both hands. Which
action should the nurse take?
• A Assure client this is a normal part of the aging process.
• B Review current list of prescribed medications.
• c Place padded dressings on top of the hands.
• D Notify the healthcare provider about the onset of the bruises.
• B Review current list of prescribed medications.
The nurse plans to conduct a physical assessment of a toddler. Which protocol is best for
the nurse to implement?
A Have the parent remove the child's outer clothing and remove the diaper or training
pants when necessary.
B Help the child take off his/her clothes, removing underwear only to conduct examination