2025 exam latest graded A+
A 60-year-old female client with a positive family history
of ovar- ian cancer has developed an abdominal mass and
is being evaluat- ed for possible ovarian cancer. Her
Papanicolau (Pap) smear re- sults are negative. What
information should the nurse include in the client’s
teaching plan?
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
Rationale: An abdominal mass in a client with a family history
for ovarian cancer should be evaluated carefully
A client who recently underwear a tracheostomy is
being pre- pared for discharge to home. Which
instructions is most impor- tant for the nurse to include
in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning c-
techniques
Encourage self-care and independence.
d- Demonstrate how to clean tracheostomy site.
,Rationale: Suctioning helps to clear secretions and maintain
an open
airway, which is
critical.
In assessing an adult client with a partial rebreather mask,
the nurse notes that the oxygen reservoir bag does not
deflate completely dur- ing inspiration and the client’s
respiratory rate is 14 breaths / minute. What action should
the nurse implement?
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
Rational: reservoir bag should not deflate completely during
inspiration
and the client’s respiratory rate is within normal
limits.
During a home visit, the nurse observed an elderly client
with di- abetes slip and fall. What action should the
nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
, d. Asses clients blood sugar level
Rationale: After the client falls, the nurse should immediately
assess for
the possibility of injuries and provide first aid as
needed
At 0600 while admitting a woman for a schedule
repeat cesarean section (C-Section), the client tells
the nurse that she drank a cup a coffee at 0400
because she wanted to avoid getting a headache.
Which action should the nurse take first?
a. Ensure preoperative lab results are available
b. Start prescribed IV with lactated Ringer’s
c.
Inform the anesthesia care d-
provider
Contact the client’s obstetrician.
Rationale: Surgical preoperative instruction includes NPO after
midnight
the day of surgery to decrease the risk of aspiration should oc-
vomiting
on
cur during anesthesia. While it is possible the C-section will
schedule or rescheduled for later in the day, the anesthesia
provider
, should be notified
first.
After placing a stethoscope as seen in the picture, the
nurse auscul- tates S1 and S2 heart sounds. To
determine if an S3 heart
A nurse is reviewing the laboratory report of a client who is 24 hrs
postpartum vaginal delivery. Theclient has a hemoglobin level of 9.0
g/dL and hematocrit of 25%. Which of the following actions shouldthe
nurse take?
a. Administer an iron supplement to the client
b. Instruct the client that the provider will check for placental fragments
c. Initiate IV access for isotonic solution with an 18-gauge catheter
d. Prepare the client for a blood transfusion
A nurse is caring for a client who is receiving magnesium sulfate by
continuous IV infusion for sever preeclampsia. Which of the following
findings should the nurse report to the provider?
a. Absence of clonus
b. Deep tendon reflex +2
c. Facial flushing
d. Urine output 20 mL/hr
A nurse is performing a heel stick on a newborn. Which of the