EXAM WITH NGN FORMAT NEWEST 2025
ACTUAL EXAM ALL QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
,A charge nurse is observing a newly licensed nurse administer an IV medication to a client
who has an implanted venous access port. Which of the following observations requires
intervention by the charge nurse?
A. A dressing is not applied to the port site after use.
B. A 22-gauge non-coring needle is used to access the port.
C. Blood return is noted prior to administering the medication.
D. A solution of 5 mL heparin 1,000 units/mL has been prepared. - CORRECT ANSWER
D. A solution of 5 mL heparin 1,000 units/mL has been prepared.
Implanted ports should be flushed after each use and at least once a month when not in use.
This practice is sometimes referred to as "locking" or "de-accessing." It is performed to
prevent the formation of blood clots in the catheter, which would disrupt the proper
functioning of the catheter. The solution of 5 mL heparin should be 100 units/mL; therefore,
this action requires intervention by the charge nurse.
A client is being discharged home with oxygen therapy delivered through a nasal cannula.
Which of the following instructions should the nurse provide to the client and family
members?
A. Use battery-operated equipment for personal care.
B. Apply mineral oil to protect the facial skin from irritation.
C. Remove the television set from the client's bedroom.
D. Wear cotton clothing to avoid static electricity. - CORRECT ANSWER D. Wear cotton
clothing to avoid static electricity.
The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly
combustible gas. The use of oxygen in high concentrations has great combustion potential
and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can
easily cause a fire in a client's room if it contacts a spark.
A nurse in an emergency department is assessing a client who sustained a fall off of a roof.
Which of the following findings should the nurse identify as an indication of a basilar skull
fracture?
A. Depressed fracture of the forehead
, B. Clear fluid coming from the nares
C. Motor loss on one side of the body
D. Bleeding from the top of the scalp - CORRECT ANSWER B. Clear fluid coming from
the nares
Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a
basilar skull fracture.
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which
of the following findings should the nurse report to the provider?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg - CORRECT ANSWER C. Chest petechiae
The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients
who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat
emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow
enter into the systemic circulation and are deposited in the lungs. The nurse should
immediately notify the provider because the client could progress to acute respiratory failure.
A nurse is assessing a client who has cholecystitis. Which of the following findings should
the nurse expect?
A. Blumberg's sign
B. Ascites
C. Gastrointestinal bleeding
D. Kehr's sign - CORRECT ANSWER A. Blumberg's sign
The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has
cholecystitis. This response can be an indication of peritoneal inflammation.