UPDATED STUDY GUIDE 2025/2026 COMPLETE ACCURATE
EXAM ACTUAL QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
LATEST UPDATED VERSION |GUARANTEED PASS A+
(BRAND NEW!) FULL REVISED
When evaluating a client's plan of care, the nurse determines that a
desire outcome was not achieved. Which action should the nurse
implement first?
A. Establish a new nursing diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the HCP to make changes.
Answer- B. Note which actions were not implemented.
Rationale: (First, the nurse should review which actions in the original
plan were not implemented (B) in order to determine why the original
plan did not produce the desired outcome. Appropriate revisions can
then be made, which may include revising the expected outcome, or
identifying a new nursing diagnosis (A). (C) may be needed if the
nursing actions were unsuccessful, or were unable to be implemented.
(D) other members of the healthcare team may be necessary to
collaborate changes once the nurse determines why the original plan did
not produce the desired outcome.
Which snack food is best for the nurse to provide a client with
myasthenia graves who is at risk for altered nutritional status?
,A. chocolate pudding
B. graham crackers
C. sugar free gelatin
D. apple slices
Answer- A. chocolate pudding
Rationale: (The client with myasthenia graves is at high risk for altered
nutrition because of fatigue and muscle weakness resulting in dysphagia.
Snacks that are semisolid, such as pudding (A) are easy to swallow and
require minimal chewing effort, and provide calories and protein. (C)
does not provide any nutritional value. (B and D) require energy to chew
and are more difficult to swallow than pudding.)
The nurse is instructing a client with high cholesterol about diet and life
style modification. What comment from the client indicates that the
teaching has been effective?
A. "If I exercise at least two times weekly for one hour, I will lower my
cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase."
Answer- C. "I will limit my intake of beef to 4 ounces per week."
Rationale: (Limiting saturated fat from animal food sources to no more
than 4 ounces per week (C) is an important diet modification for
lowering cholesterol. To be effective in reducing cholesterol, the client
should exercise 30 minutes per day, or at least 4 to 6 times per week (A).
Red meat and all proteins do not need to be eliminated (B) to lower
,cholesterol, but should be restricted to lean cuts of red meat and smaller
portions (2-ounce servings). The low density lipoproteins (D) need to
decrease rather than increase.)
An obese male client discusses with the nurse his plans to begin long-
term weight loss regimen. In addition to dietary changes, he plans to
begin an intensive aerobic exercise program 3 to 4 times a week and to
take stress management classes. After praising the client for his decision,
which instruction is most important for
the nurse to provide?
A. "Be sure to have a complete physical examination before beginning
your planned exercise program."
B. "Be careful that the exercise program doesn't simply add to your
stress level, making you want to eat more."
C. "Increased exercise helps to reduce stress, so you may not need to
spend money on a stress management class."
D. "Make sure to monitor your weight loss regularly to provide a sense
of accomplishment and motivation."
Answer- A. "Be sure to have a complete physical examination before
your planned exercise program."
Rationale: (The most important teaching is (A), so that the client will not
begin a dangerous level of exercise when he is not sufficiently fit. This
might result in chest pain, a heart attack, or stroke. (B, C, and D) are
important instructions, but are of less priority than (A).)
, The nurse is teaching a client proper use of an inhaler. When should the
client administer the inhaler-delivered medication to demonstrate correct
use of the inhaler?
A. Immediately after exhalation.
B. During the inhalation
C. At the end of three inhalers
D. Immediately after inhalation
Answer- B. During the inhalation.
Rationale: (The client should be instructed to deliver the medication
during the last part of inhalation (B). After the medication is delivered,
the client should remove the mouthpiece, keeping his/her lips closed and
breath held for several seconds to allow for distribution of the
medication. The client should not deliver the dose as started in (A or D),
and should deliver no more than two inhalations at a time (C).)
An IV infusion terbutaline sulfate 5 mg in 500 mL of D5W, infusing at a
rate of 30 mcg/min, is prescribed for a client in premature labor. How
many ml/hr. should the nurse set the infusion pump?
Answer- 180
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn)
7.5 mg PO. Zaroxoltn is available in 5 mg tablets. How much should the
nurse plan to administer?